Helpful visits or way to milk the system?

The Wall Street Journal’s investigative report on Medicare Advantage (MA) deftly uncovers little known concerns about how these plans harm taxpayers. Specifically, these plans exploit Medicare by manipulating coding to increase their payments. This particular report on The One Hour Nurse Visit illustrates how these private insurers use coding to gerrymander a patient's list of illnesses, making them look sicker, so the insurers can collect billions in higher government payments.

This nurse visit strategy is merely one of hundreds of practices by the insurers to increase their government reimbursement through coding. What makes this manipulation of coding possible is complexity. Coding is unbelievably complex and this complexity creates a gray space where MA plans can justify their actions as defensible. In this case, insurers argue

these nurse visits are good for patients, when in fact, the nurses are not there to treat anyone, they are there to gather new diagnoses to increase payments.

Unfortunately, Medicare, which does acknowledge this problem, seeks to cure it by making coding even more complex and by increasing their efforts at fraud oversight. This strategy has not worked and will not work. The answer is to decrease the use of coding for the determination of payments.

Basing premium payments on a patient's list of diagnoses, in theory, is a good idea. However, the continuous increase in coding complexity creates the gray space and invites fraudulent actions like the One Hour Nurse Visit. There are less complex methods of adjusting patient risk for insurance premiums that are technically less accurate but are simple and not subject to billions of dollars in manipulation. Healthcare needs to start embracing simple solutions to our challenges in healthcare payment.

Why there's a shortage of primary care doctors

Two recent articles illustrate how healthcare policy consistently creates barriers to advancing primary care.

In the first, Debra L. Glasser, MD boldly declares that internal medicine primary care is dead, and she offers a powerful summary of the reasons for the decline:

"Why are they not choosing primary care? Primary care is the lowest-paid specialty at a time when medical education is not strongly subsidized (medical students can incur up to $500K of debt). It no longer offers professional satisfaction, continuity of care, and collegiality.

Primary care physicians are the most overburdened by administrative tasks. They are increasingly pressured to see more patients in shorter time slots, and it feels impossible to offer quality care. Many work for large systems where they feel powerless to effect change.”

The second article by Randy Dotinga reports on recent research documenting the excessive burden of numerous and diverse quality measures required of physician value-based programs. One physician group had 57 different quality measures across multiple insurers. The research concluded that “The magnitude of that number surprised us…Primary care physicians and their practices have a lot on their plate. Now we know one of those things is a very large number of different quality metrics to pay attention to, measure, report on, and implement.”

By the way, there is little evidence that using these burdensome quality measures improves the quality of care.

In summary, we have a severe and increasing shortage of primary care physicians to serve the growing elderly population, and we have intentionally created a health policy to make it worse. We need to immediately start creating health policy to promote and support primary care physicians. That policy needs to pay them better and dramatically simplify their work environment. My book The Journey’s End offers one path to make that policy a reality.

The Problem Isn’t So Much Insurer Vertical Integration as it is the Use of Coding to Measure Risk for Payments

The recent New England Journal of Medicine article on the dangers of private health insurer vertical integration/consolidation raises critical issues for health policy. Ironically, a recent investigative Wall Street Journal article also raises concern about the dominance of the private health insurer United Healthcare. The NEJM article describes the issues well in their title: The Dangers of United Healthcare for All.

One of the critical points of both articles is the explosion of Medicare and Medicaid patients being converted into private insurers - and United Healthcare leads the conversion. This privatization of government insured patients was meant to encourage competition, improve quality and lower costs. Of course, none of these benefits have materialized. The evidence suggests that the government pays more for these patients' care in private insurance. The quality of care declines and importantly, the caregivers are paid less by private insurers than they were by the government. At the same time we are “placing a handful of insurance companies in control of the healthcare delivery system.” 

Sadly, the remedies offered in both articles will not work because they don’t understand the real causes of the poor results. 

Coding makes healthcare payments insanely complex and the cost of the coding is not worth the results. Coding complexity invites fraud. Private insurers use coding to make everything more complex - the denial claims, the denial of coverage and the level of payments. The private insurers use coding complexity to justify these activities and to optimize their profits. More coding changes, more fraud oversight and more antitrust oversight will not fundamentally fix the abuses of coding complexity - we have decades of experience to demonstrate these remedies do not work. 

Serious reform efforts need to focus on simplification and the reduction of coding to determine provider payments and insurer premiums. These adjustments will reduce insurers' abuse of the system, improve quality, and lower costs. Go to www.thejourneys-end.org for more details on these solutions.