Saturday, May 11, 2013

Mission Critical: Target Missed: $34.1 Billion in Overpayments to MA Plans in 2012

$34.1 Billion: Overpayments to MA Plans in 2012

By: Kameron Gifford, CPC 5/11/2013

Medicare Advantage plans received $34.1 billion in overpayments in 2012, according to a study published today in the International Journal of Health Services by Drs. Ida Hellander, Steffie Woolhandler and David Himmelstein titled "Medicare overpayments to private plans, 1985-2012: Shifting seniors to private plans has already cost Medicare US$282.6 billion.”
This number is even more alarming if we consider that there were only 3,518 private health plans providing benefits to 13 million Medicare beneficiaries in 2012. That is, on average, $100,000,000 in overpayments per plan.
Who is regulating this spending and where is it going?
It is a typical Monday morning at my office, I won’t transfer the phones for another 15 minutes, but I already know that we are in for a long day. My computer screen informs me that we have received 73 refill requests over the weekend and I have 2 “emergencies” that “really need to see the doctor”. After politely reminding, that we do not accept walk-ins, I agree to work them in and they are happy to wait.
Mrs. Jones saw her cardiologist on Friday and he changed her BP medication, but she couldn’t remember what else she was asked to stop. Our patients are taught early on to bring all of their medicine bottles with them to their appointments. After 15 years, this has become habit and before I even ask I have two plastic bags filled with various prescription bottles, creams, inhalers and vitamins piled in front of me. It takes about 3 minutes for us to retrieve the notes from her cardiologists and another 3 minutes to mark a large red “X” across three bottles. Mrs. Jones thanks me over and over again for my help and I can see the relief in her face as she proudly shows me the notes she has taken in her journal. Under her Medicare Advantage HMO, Mrs. Jones doesn’t have to pay a copay when she sees her PCP and there is no charge for our services today.
Mr. Garcia is next. He states that he doesn’t remember why he is here, but then his eyes light up, as he pulls out a crumpled up piece of paper from his back pocket. In blue pen, his daughter has written down his temperature, BP and pulse readings from 5 various times and even made notes of some symptoms her father had been complaining of over the weekend as well as a list of a current medications. I made a mental note to call Maria after lunch and thank her (HIPPA release on file gives us permission to coordinate care with his daughters and wife). No one was able to get off work to bring her dad this morning, so he had to ride the bus. By the time he got there he was so tired and anxious from the journey (not to mention early dementia) that he couldn’t remember anything except that little note in his pocket.
After seeing the doctor, orders are given for a urine to be collected. A quick look under the microscope and in less than 10 minutes the origin of the fever was discovered to be an acute UTI. A prescription for antibiotics was emailed to his pharmacy and Mr. Garcia was feeling much better in 48 hours. The cost of his care was $3.14 for the urinalysis done in the office and he took his first dose of Cipro at 9:15 AM. His total out of pocket cost came to $5.
Tragedy averted by a simple act of kindness? Perhaps, but I prefer to use the modest words of my father, “It’s Just Good Medicine!”
His primary care practice is still located within 15 miles of where he completed his residency 35 years ago. Over 50% of our patients have been with the practice for more than 20 years, and our typical patient is an 83 year old male with 3 or more chronic conditions.
In 2012, with a patient mix of 65% Medicare Advantage, 25% Medicare and 10% Commercial patients we posted real profits of over $400,000.
My father was a business man first, physician second, and true to his roots, he has spent his career working to provide quality, comprehensive, preventive care at a tremendous cost savings to both his patients and their health insurers.
The structure of his practice closely resembles the early days, one physician and 3 staff members. In some respects, we still practice “old school” medicine.

When you call our office, we still answer the phone, not a confusing recording. The majority of our patients wait less than 5 minutes to be seen and can be worked in same day if necessary. A patient’s history is not completed in the waiting room by placing checkmarks next to applicable conditions. It is taken in question and answer form face to face with the physician. We schedule appointments every 15 minutes, but new patient visits average 30 minutes. When a patient is referred for a test or to a specialist we make the appointments. This ensures that WE get the report. Every patient gets an annual comprehensive exam, if they are willing (and most are.) All diabetic patients are seen every 3 months fasting, even when they complain. Changes in medications (such as BP) are followed up on in 2-3 weeks to ensure target levels. Everyone in the office works together to ensure that all patients have a current LDL and all efforts are made to keep it under 100. Prescription medications are not refilled for 12 months at a time. We allow enough refills only until the next appointment to provide a safety net for “lost patients”. This system, although labor intensive, provides the best outcomes for our patients.

All referrals and authorizations are processed by set protocols that deliver continual oversight and monitoring of our patients between home providers, specialists, inpatient facilities, outpatient facilities and rehabs. Most importantly, we strive to educate our patients at every point along the way.

The brilliance is in the simplicity of that solution my father sought back in 1979 to guarantee his patients received the “Gold Standard” of care. It is that system that he has refined and modified over and over again, year after year, to continually do what is right for the patient.
In Managed Care terms, our practice was able to provide high quality care at an average savings of $400 per member when compared with our counterparts.
The majority of Medicare Advantage plans are operating light years behind where they need to be. Employer sponsored health plans have long been reaping the benefits of their innovative Wellness Programs designed to engage employees as partners instead of numbers.
Correct me if I wrong, but wasn’t it this expertise that the government so desperately sought to save our Medicare program. Twelve years have passed since the inception of “Part C” and what value have we added to America’s health system for seniors?
Last week, I received a call from one of my patients, who had been with our practice for about a year. During that time, her MA plan, like many others experienced many “system errors” a common side effect these days of healthcare companies trying to frantically upgrade hardware and software to comply with new regulations. Her call that morning was to tell me that she was switching doctors. It wasn’t because she had been treated badly or because she didn’t like the doctor. Her reason was simple. Her insurance company had denied our third appeal to cover a routine check-up for rheumatoid arthritis and again refused to pay the $49 cost of her visit. I couldn’t believe what I was hearing. She went on to say that when she called the number on the back of her card to ask why she was again told, it was “because her PCP didn’t obtain an authorization for services.”
The patient had a valid authorization, but it had “accidentally” gone into the wrong system. We all make mistakes, but it is what we do to correct the situation that defines our integrity.
Even after submitting all supporting documentation and following “standard procedures” the decision was final: DENIED.
Now, allow me to pose the question again, where did that add value?
Medicine is the only trade in the world in which we provide a service and then have to fight to get paid. Where is the accountability to the patient who signed up with the plan or to the tax payers who fund the system?
$31.4 Billion in Overpayments to Medicare Advantage plans and my patient can’t sleep at night because she is worried her rheumatologist (the only one in town) won’t see her next month…
As Americans, we must demand fiscal responsibility and stop allowing seniors to pay the price.
The future of our healthcare system depends on putting the patient first, and change must be initiated at the initial point of contact. Care must be integrated, and flexible enough to fit the needs of each patient. Disruptive innovation doesn’t necessarily mean a new idea or concept, but additionally represents the ability to improve the experience for our patients.
Our public health care system is in serious trouble, we must act before it is too late.
Medicare Advantage, as it is today, must be changed. We need to eliminate the opportunity for big business to profit from this system, and give the power back to the physicians and patients. I can’t help but ask, have we forgotten who pays the premiums?
We must create educational opportunities for patients, office staff and providers to empower a partnership for greater health. Solutions founded in the most basic ideas of prevention and primary care combined with patient centered technology will provide long term stability and positive outcomes. The greatest thought leaders of our time have yet to be defined, who will be the next disruptor?