Category Archives: Patients

Paying for IVF

You paid how much for me?

You paid how much for me?

Advances in fertility treatment have greatly expanded the number of people who can become parents. But treatment is expensive and –in most states– is not covered by health insurance. Patients often pay tens of thousands of dollars out of pocket for in-vitro fertilization and surrogate pregnancies, and face tough decisions about whether to continue treatment when initial attempts fail.

Kaiser Health News (Infertility Patients Finding Creative Financing Help) documents the growing number of options available to fertility patients. Clinics and shared-risk programs provide full or partial refunds for customers who don’t end up with a baby, in exchange for paying somewhat more upfront. These programs look like a good way to hedge against the risk of multiple cycles or failure to conceive. Those offering the programs must like them, since they increase the addressable market and probably boost average revenues per patient.

So on balance I think these programs are good. But it’s worth stepping back to consider that a mediocre Reproductive Endocrinologist can easily make a seven figure income, especially in those states that don’t mandate coverage for fertility treatments. In the 15 states that do mandate coverage insurance companies use their negotiating power to pay more reasonable rates than what any individual could hope to negotiate, and there’s no need for the consumer to participate in shared-risk or similar programs. Insurers also get a break on the price of expensive fertility drugs.

The downside of the mandate is that it increases insurance premiums for everyone, although those increases may be partially offset by reduced costs for neo-natal intensive care (when self-pay patients push for more embryos and end up with twins and triplets).

I live in a mandate state and I’m glad that I do.

photo credit: Gonzalo Merat via photopin cc
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By healthcare business consultant David E. Williams of the Health Business Group

 

 

Patient portals: Hiding in plain sight

Many physician offices have patient portals, since they’re a requirement for Meaningful Use Stage 2. But a new survey from Software Advice confirms what we knew intuitively – these portals don’t get much use. Patients don’t know they exist and doctors don’t use them a whole lot. That’s kind of odd considering that portals can be useful and efficient. They’re good for checking lab results, asking non-urgent clinical questions, renewing prescriptions, managing appointment schedules, patient education and paying bills.

Why then is uptake so low? I have a few ideas:

  • The systems are clunky -frustrating to navigate, often down for maintenance or for no explained reason, and slow
  • Workflows are awkward. For example a physician may have access but her admin may not
  • There’s often no value proposition for a physician who wants to use a portal
  • Messaging is inflexible with no access to attachments web links or other enhancements
  • Some of the more important communications, like sharing a diagnosis don’t lend themselves to asynchronous communications
  • Privacy and security remain concerns and the required safeguards create barriers

Contrast the weak state of portals, which have been available in one form or another for 20 years, with other changes in communication that have been embraced much faster. Think texting, Skype, and mobile commerce, all of which have rocketed to prominence since patient portals were invented. I do think we’ll get there, but it will take a new generation of doctors, patients, software developers and payment models to make it happen.

You can find the original item from Software Advice here.

Narrow networks: Get used to it

Narrow but workable

Narrow but workable

Many health plans unveiled “narrow network” plans recently as part of the Affordable Care Act. These plans cover a limited number of doctors, hospitals and other providers and often pay nothing for out-of-network coverage. Predictably, some members are upset as documented today by Kaiser Health News (Limitations of New Health Plans Rankle Some Enrollees.)  Some consumers are upset that they can’t see specific doctors who they may have seen in the past and that the list of available providers isn’t terribly long.

Insurance commissioners and lawmakers are hearing complaints and some are considering taking action. And while it definitely makes sense for regulators to take an interest in network adequacy and to prevent abuses, in my view narrow networks have become a crucial part of healthcare affordability and need to be maintained.

Here’s why they’ve become prevalent: The Affordable Care Act prevents health plans from using many of their traditional tools for limiting costs. They can’t reject sick or high-risk patients, can’t charge them more, can’t cap annual or lifetime benefits, and have to provide a set of proscribed services. At the same time, the plans are subjected to apples-to-apples comparisons on health insurance exchanges by price-sensitive buyers. The result is that plans take the main remaining step they can to be control costs: limiting their networks to providers willing to accept lower reimbursement rates.

Most shoppers care mainly about price so this is a very sensible approach for the health plans. And for many customers it’s a way to afford insurance that provides a wide array of benefits. In some markets (including Massachusetts) narrow network products that exclude the highest priced, largest healthcare systems provide very substantial discounts while still delivering high quality providers.

Narrow networks are becoming increasingly important. In 2010, before the Affordable Care Act, I wrote Narrow networks. Nice idea but no panacea. I listed six reasons why such networks were having a limited impact. Some of these factors are still present, but others are less prominent. For example, the development of integrated delivery networks mean that health plans can contract with these larger entities and get essentially all the providers they need, the emergence of risk-sharing through ACOs and similar arrangements aligns incentives, and in general there is more price sensitivity. At least a few provider organizations are now positioning themselves as value players, ready to address an emerging market segment.

 

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

Medicaid: Program for the poor should not impoverish doctors and hospitals

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Medicaid beneficiaries deserve the same access to healthcare services and products as people with commercial insurance or Medicare. But since Medicaid pays doctors and hospitals 27 to 65 percent less than commercial health plans (according to a new GAO report), it makes it awfully difficult for providers to be payer agnostic. Sure enough, we see even supposedly mission-driven non-profit healthcare systems looking to maximize their share of the commercial population by catering to that group.

That’s a real public policy problem as the proportion of patients with Medicaid increases, and it presents providers with an unreasonable dilemma.  In many states, doctors or hospitals that take care of a high proportion of Medicaid patients will find themselves in financial distress. That’s not fair to them or the Medicaid recipients. Frankly it’s also unfair to the commercial customers who may be overpaying to compensate for Medicaid underpayments.

Compare Medicaid with the Supplemental Nutrition Assistance Program (SNAP), aka Food Stamps. SNAP recipients don’t bankrupt supermarkets. That’s because the government pays the same price for groceries as any other customer. The SNAP program doesn’t demand that the grocery store sell products below cost, nor should it. SNAP recipients have to be savvy about how they use their benefit, seeking out high value products and retailers to stretch their dollar.

Realistically we won’t see the disparity between Medicaid and commercial payment rates erased any time soon. It would be just too expensive. But there are steps that can and should be taken:

  • Narrow the gap over time from the current 27 to 65 percent to something more like 10 to 15 percent
  • Introduce more progressive payment mechanisms –like Medicaid Accountable Care Organizations– that provide health systems with incentives to contain costs and improve quality. Healthcare systems that figure out how to help Medicaid members become healthier for a lower cost will prosper –analogous to what Walmart does with SNAP payments
  • Provide incentives for Medicaid beneficiaries to seek lower cost, higher quality care. Let’s not be paternalistic and assume that people on Medicaid aren’t capable of identifying high quality, low cost services.. I’ll venture to say that many lower income Americans are savvier shoppers than average consumers, if only due to necessity

The GAO report should be a wakeup call. It’s time to do something about these disparities beyond simply shrugging our shoulders.

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

Health Business TV: Cash for specialists, eVisits again, nursing shortage mythology

https://www.youtube.com/edit?o=U&video_id=SqEf7ry112cIn this fifth episode of Health Business TV, I discuss my interview with HelloMD about cash payments to specialists, the long and slow evolution of eVisits, more on the nursing shortage myth, the United Independent Party in Massachusetts, and an update on the proposed 29% health insurance premium hike for our business..

Please subscribe to the YouTube channel and tell your friends!

 

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

 

eVisits: the 30 year march?

This guy moves faster than eVisit adoption

This fella moves faster than eVisit adoption

When I first started working in healthcare I was told that innovations can take a long, long time to be adopted. Now I’m old enough to have experienced it for myself.

The big news in the Seattle Times this week?

“To cut medical costs and diagnose minor ailments, WellPoint and Aetna, among other health insurers, are letting millions of patients get seen online first.”

“In a major expansion of telemedicine, WellPoint this month started offering 4 million patients the ability to have e-visits with doctors, while Aetna says it will boost online access to 8 million people next year from 3 million now.”

This has been a long time coming, and we’re still at the early stages of adoption, with plenty of naysayers remaining. I first worked on eVisits (or webVisits) in 2001, when Healinx (now RelayHealth) commercialized them. Researchers at Stanford and UC Berkeley studied the webVisit and concluded that their use cut total medical costs while improving patient and physician satisfaction. Here’s a press release from January 2003 on the study (Final Results: webVisit(SM) Study Finds RelayHealth Reduces Cost of Care While Satisfying Doctors and Patients).

Here’s what I said about it five years ago (eVisits continue their slow, steady rise) –before the iPad, Meaningful Use, or the Affordable Care Act:

It’s interesting to be in late 2009 and see e-visits described as a “disruptive innovation” that “the medical establishment is fighting.”  It’s a sensible concept, fairly straightforward to implement, efficient, and effective for certain situations. Yet growth has been slow. Part of the issue is that it’s health care we’re talking about, where innovation tends to be retarded when it involves changing physician practices. Another, related problem is that there’s no great financial incentive for the physician or patient to make a change. Health plans that do cover e-visits often charge the same co-pay for patients as for in-person visits, even though they often reimburse physicians at a lower rate.

My guess is that over the next decade we’ll see e-visits become common. Why?

  1. Adoption will follow the typical S-shaped curve, and we’ll soon get to the steep climb almost regardless of other changes
  2. More patients and physicians will simply expect to communicate online, as they do in every other area of their personal and professional lives
  3. Payment systems will evolve to support e-visits, rather than penalize them
  4. Adoption of electronic systems in physician offices in general will enable e-visits
  5. Supporting technologies will evolve and emerge. These include remote monitoring, higher bandwidth, personal health records, and mobile applications

Enjoy the next decade and don’t expect things to change too quickly.

Halfway into the decade these five factors are still playing out. Having said that I could probably have just reposted the article and changed the date and no one would have noticed.

Will things speed up dramatically over the next five years? In 2019 will we still be reading articles about this “novel” approach? I hope not but fear that we may.

photo credit: Nasitra via photopin cc

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

 

 

HelloMD helps patients with cash jump the line for better treatment

Mark Hadfield, HelloMD CEO and founder

Mark Hadfield, HelloMD CEO and founder

Mark Hadfield makes no bones about the fact that the US is moving to a two-tiered medical system, where those with the means to pay more get better, faster treatment. His company, HelloMD helps in-demand doctors –mainly specialists– opt out of the third-party reimbursement system and serve the more lucrative, cash-paying patients.

In this podcast interview, Hadfield describes how his company is addressing the high end of the market. He explains how HelloMD fits in the broader ecosystem of concierge practices, medical tourism and high-deductible plans. And he shares HelloMD’s geographically-focused strategy to build a marketplace to serve its niche.

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