Cooperating for better care.

Robert Whitcomb

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‘Repricers’ slash hospital bills


Read how a Pennsylvania company, ELAP Services, helps slash hospital bills for self-insured employees.

ELAP does cost analysis for its clients by studying hospitals’ department-by-department costs that they reported to Medicare.

The Philadelphia Inquirer reports that “For major back surgery, for example, ELAP employees, called ‘repricers,’ go through every line of what could be a 30-page hospital bill and adjust the charges based on the hospital’s actual costs, using Medicare cost data. Then ELAP adds back a predetermined percentage of the cost, typically 12 percent to 25 percent, ‘to allow a fair margin above that cost,’ (ELAP founder Stephen P.} Kelly said.”

”In a case that landed in court, a hospital billed $312,655. ELAP said its client should pay only $99,476, or 32 percent of gross charges….That determination stood up to a federal judge’s scrutiny in a 2013 court case.”

”Kelly, 60, founded ELAP as an antidote to what he saw as a lack of transparency in medical billing for employers trapped in relationships with third-party administrators who have proprietary contracts with hospital networks.”


Some California narrow networks getting even narrower


California’s biggest health insurers are sticking with their often-criticized narrow networks of doctors, and in some cases they are cutting the number of physicians even more,” reports the Los Angeles Times.

Further, the paper reports, ”the state’s insurance exchange, Covered California, still has no comprehensive directory to help consumers match doctors with health plans.”


Hospital admissions keep falling

Inpatient admissions at many hospital systems kept falling during  2014’s third quarter.  Changes tied to healthcare reform were cited, including Medicare’s “two-midnight rule,” which has shifted many patients to ”observations” from admissions. But of course, Medicare is doing other things with financial incentives to control costs by shifting patients away from hospitals.

Further explaining the decline is the increase in high-deductible health plans with hefty co-payments and co-insurance.



The old and outpatient future of healthcare



Christmas in a nursing home.

To see the future of healthcare, think old and think outpatient.

An article in The Boston Globe predicts that while healthcare will continue to be a “reliable engine for job growth in coming years” that growth will slow as payers seek to control costs.

”More important, the aging population is increasing demand for nurses, physical therapists, nursing assistants, and home care workers,” the article says.

“The wave of the future is going to be geriatrics,” Tammy Retalic, chief nursing officer at Hebrew Rehabilitation Center in {Boston’s} Roslindale, a division of Hebrew SeniorLife, told the Globe.

The paper also reported that in the state’s ”two-year forecast for 2013-2015, the state projects 6.8 percent job growth in outpatient healthcare services, compared with just 1.4 percent for hospitals. Meanwhile, the shortage of primary care physicians is increasing demand for nurse practitioners and certified midwives.”

“{C}linical documentation, medical coding, billing, and information technology” are seen as among the big growth areas.



‘First do no harm’ in a complicated world


Following Hippocrates’s dictum “First to no harm” can be a lot easier said than done in today’s complicated healthcare world.

MedPage Today asked  medical-ethics experts and a variety of other health professionals:

”Under what circumstances should physicians participate in situations where harm can come to people (executions, prisoner interrogations, assisted suicides), if the physicians can mitigate the harm?”


Minn. slashes number of early induced childbirths


Minnesota reports progress in efforts to reduce induced early elective childbirths.

The Minneap0lis Star Tribune reports that “a group of 85 Minnesota hospitals — which provide 99.8 percent of deliveries in the state — has instituted ‘hard stop’ policies that discourage medically induced labor unless there are legitimate medical reasons. Since 2010, they have reduced elective inductions occurring before 39 weeks gestation by a remarkable 94 percent.”

Public-health officials have that childbirth even a week ahead of schedule ”increases the risk of complications and the need for costly neonatal intensive care. ”

Improving care and saving money. Sounds good. Good old Scandinavian civic-minded Minnesota.


Minn. ruling expands hospital medical staff’s legal powers


In a  case that has gotten national attention, he Minnesota Supreme Court has ruled, 5-2, that medical staff bylaws can constitute a legally enforceable contract between a hospital and medical staff. At the least, the ruling is likely to increase efforts to get physicians to voluntarily align with hospital needs to avoid litigation.

West Central Tribune also reported that  the justices ruled that ”a medical staff that meets criteria outlined in state statute has the capacity to sue and be sued.”

”At issue was a 2012 decision by Avera Marshall  Hospital  in Marshall, Minn.}to introduce new medical staff bylaws, allegedly without input from the medical staff. A group of doctors on the medical staff sued the hospital, claiming the new bylaws stripped physicians of most of their rights and responsibilities and gave the hospital board of directors the controlling power in processes requiring medical staff direction.”
Justice Alan Page, writing for the majority, said that because the medical staff “is composed of two or more persons who associate and act together for the purpose of ensuring proper patient care at the hospital” it meets statutory criteria giving it the power to sue and be sued.

Some fear that the ruling will encourage conflict between medical staffs and hospital boards of directors.



Works in progress in ACA innovation lab


Illustration by Theodor von Holst from the frontispiece of the 1831 edition of Mary Shelley’s 1818 novel, Frankenstein; or The Modern Prometheus.

Federal officials  have  submitted to Congress a progress report on the work of the  laboratory created by the Affordable Care Act to help transform how medicine is delivered and financed. There are a few successes but the lab mostly reports  that its projects are works in progress.

And “some 2.5 million patients and more than 60,000 hospitals, clinics and doctors will soon be participating in models run by {the lab called} HHS’s Center for Medicare and Medicaid Innovation, the center estimated in its biennial report,” reported Kaiser Health News.

Programs include Accountable Care Organizati0ns, efforts to end preterm births and to lower hospital readmissions for nursing-home patients, and big grants to states to improve care  (and  better control costs) for all  payers and patients, including those with private insurance.




Bad luck the biggest culprit in cancer


Bad genetic luck is mostly to blame for cancer — not  behavior — says this study,  by mathematician Cristian Tomasetti and geneticist Bert Vogelstein, both of Johns Hopkins University. We wonder what effect this will have on funding incentives for people to change bad behavior — smoking, inactivity and so on.

Bloomberg News suggested that the study would support ”focusing more resources on diagnosing the disease in early stages and on treatments to reduce mortality rates.”

The news service also noted that the researchers ”cautioned that the study isn’t a license to engage in unhealthy behavior. ‘Cancer-free longevity in people exposed to cancer-causing agents, such as tobacco, is often attributed to their ’good genes,’ but the truth is that most of them simply had good luck,’ Vogelstein said.”



Foreign patients a bonanza for Boston Children’s Hospital


Boston’s Children’s Hospital reported that it earned $113 million on operations in the fiscal year that ended Sept. 30 — a 28 percent jump from the year before.

“The growth was fueled largely by international patients: Revenue from these patients soared 47 percent from last year, nearly six times the pace of revenue growth from local patients,” The Boston Globe reported.

Children’s has increased marketing abroad   in recent years to attract new international business.”

As with Ivy League and other prestigious parts of American higher education, prestigious teaching hospitals such as Boston Children’s are in a strong position to lure affluent foreigners who can pay full freight. This business can offset some of the losses from serving American patients. But the vast majority of American hospitals, of course, lack that allure.



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