Not What You Wanted To Hear

Do you like being told no? Of course not. Who does? Maybe crazy people but certainly not your average run of the mill person. We all like to get our way and get what we want. That is human nature. We are needy beings that want want want. However, even Mick Jagger knew that we don’t always get what we want.


Hey now, don’t give me that look. I can see you giving me an eye roll and moving that mouse to close the browser window. Just stop for a minute. I have a point here. I promise.

Our modern culture is built on the premise that anything you do can be made faster and/or more efficient with the incredible power of (fanfare please) the internet. I would venture to say that in a lot of ways this is true and if it doesn’t make it faster than at least it’s more convenient. Shopping is easier, taxi rides are easier, education is more accessible, banking is easier, and meeting new people is as simple as a swipe right. So what about healthcare?

A few posts ago I spoke about how the data we leave behind us can be analyzed to make our healthcare easier and cheaper. As a consequence of that efficiency and cost-effectiveness, we may not get the care we are used to or even the care that we feel we want. This isn’t because we are getting subpar care. It is just that we don’t necessarily need everything that might have been done in the past. It is that efficiency and cost savings at work. That fact is that you as a patient may not have much control over your care at all. That may or may not be such a bad thing but I can think of a few situations where someone might get a little ticked that they are told no. angry-2191104_1920Sadly, in our modern world, some adults seem to turn immediately into toddlers when they don’t get their way. Just watch the customer service counter at your local big box store when someone is told they can’t return the doodad they bought 3 years ago… Epic meltdowns for sure. It’s the kind of stuff viral videos are made of.

Now back to the story. Coordinated care groups, cooperatives of providers, and even the participants within a payer network may not allow a patient access to certain procedures they deem unnecessary or superfluous or allow a patient to see anyone outside of the confines of their group. Why you ask? Because they feel that if they control what procedures are done and who a patient gets to see for a specific procedure then they can guarantee the quality and the cost of an entire episode of care. And if they cannot guarantee it then at least they would have a pathway to open communication to make sure they can adjust or understand better the care a patient receives. So that means that patients can’t really choose who they get to go to or whether or not to get the “extra” tests that somehow make them feel more trusting of the care they are receiving. Despite the fact that healthcare should be all about choices, those choices may start to dwindle and if you start an episode of care, say for a surgery, with one group then you likely won’t be able to move to another.

Now I imagine a lot of you thinking “What is this guy talking about? Of course I can choose what doctors I see and what providers I want to use.” But if you think about it, I don’t mean that you can’t choose what you want, only that you won’t be able to do so without consequences. A doctor who is being paid based on the health outcome of your care will be hesitant to let you out of their “area of influence” so to speak. Also, your insurance company will not be pleased and may force you to pay more if your choice moves you into a situation where quality can no longer be measured effectively. (This brings up the issue of how to measure quality which is not an easy question to answer.) There is a silver lining here though. Remember that things would not be as they are now. If you are in the midst of an episode of care it is likely that the group doing the treating is already pretty good since they will get paid based on the quality of care that they administer and not just by the procedures they complete.

So remember that even though value-based care may mean that you don’t get the same things that you used to, it also means that you are probably getting a better deal anyway. Everyone wins but only if we let the system work for us and try not to work against it. It is hard to lose control (if we even had it to begin with) but giving up some things means we can reap the benefits elsewhere. In this case, your bank account or in a more grandiose fashion the coffers of the whole country. Nothing is ever perfect but if we let the change take hold we can all be better off. In closing, I challenge you not to start humming the Rolling Stones after you read this. I said no. Don’t you do it!

See the theme here?

Bad Apples and Sour Grapes

Healthcare fraud is a consistent problem that is ever evolving and adapting to the regulations and restrictions put in place to hinder it. Once one avenue is stopped, those individuals that were cashing in are likely to move to another area and begin anew. So the question I wanted to address here is how Value-Based Healthcare will impact an industry that is rampant with fraud.

In a VBH model the focus on collaboration of providers and coordinated care means one very important thing that is missing from a volume based model, communication. Currently a large portion of fraudulent claims to healthcare payers are made by solo providers that are only one part in the chain of treatment. In a VBH world the chain becomes a web and lots of people suddenly see what procedures have been done, what drugs are prescribed, what tests have been performed and treatments administered. Even my 4 year old will tell you that when someone is watching… you shouldn’t do something you know is wrong.

angry child
If I can’t see them, they can’t see me, right?

This is even more important when a group of providers can all benefit from the administration of high quality and cost-effective care to their patients. It is as simple as peer pressure. “My friends made me do it” is a pretty weak excuse except when what they made you do is not commit a crime.

Now I don’t want to make it seem that all avenues of fraud are closed by a VBH system. In fact existing schemes can still flourish it just might be a little more difficult to pass some things by your colleagues. That is unless your colleagues all want to cash in too. So now what you have is a web of providers all collaborating to coordinate care and defraud the payers. If a large portion of the group is “in” on it then there is really not much that can stop them from cashing in… except that quality is being measured by external reference frames. What I mean is that the metrics that have to be reported in order for the assessment of quality to be made are also being reported by lots and lots of other provider collaborations and groups. That assessment of quality and the subsequent payment are therefore being evaluated rather guaranteed and a group of coordinated fraudsters could in fact lose money if their quality and cost measures fall below acceptable levels.

So the system of quality review and measurement is self-correcting right? Sure, in many cases it would be. That is of course (see I told you they always find a way) unless the quality measures are being fabricated as well. What you have now is a group of providers, institutions and patients all working together to get money out of the system. The trouble is that this would be terribly complicated and probably difficult to organize. Unfortunately I am constantly surprised as how innovative and devious people that have been convicted of healthcare fraud can be. Is it out of the realm of possibility? No, certainly not. Is it likely? I would put it at a low or medium-low risk.  The ways a scheme like that could fall apart are too numerous to count so in my opinion it just wouldn’t be worth the effort to make a few extra percent on an episode of care.

So this brings me to my closing. Right now what healthcare fraud really looks like is a number of bad apples all hanging out in the barrel making it all look bad.

bad apple
Fraudster in fruit form

VBH would do a great deal to pick those out and throw them away. The only trouble then would be the groups of sour grapes that spoil the system. Fruit metaphors aside I think I have made my point. The trouble today with fighting healthcare fraud is that it’s often very difficult to weed out the bad from the good, like I said they are really good at hiding. VBH can go a long way to shining light into the dark places but I certainly don’t think it will go as far as painting red arrows that say “Fraud This Way”.


Disclaimer: This Blog is for educational purposes only as well as to provide general information and a general understanding of the topics discussed.  The Blog should not be used as a substitute for legal advice and you are advised to seek additional information from your insurance carriers, Medicare and/or Medicaid agencies for additional criteria and regulations regarding these services.

The Invention of the Minivan

Imagine, if you will, a country where everyone moves from place to place in single person combustion engine vehicles. A country where all the laws, expectations, and infrastructure is built to support only single person vehicles. In this world of singular travel, the population realizes that it is inefficient and that all of these single person vehicles are burdensome not only in terms of space but of pollution and traffic. In order to change their ways and improve the acceptable methods of travel they begin to make laws requiring change and the creation of… the minivan.

Minivan coolness may vary

This new multi-person vehicle is more efficient, produces less pollution per person, and is superior to the single person vehicles in almost every way. This leap in progress does not come without its drawbacks. For example, many roads have not been created for a vehicle as wide as a minivan and often cause traffic jams where they once never existed. Revenue from tolls suddenly begins to drop. The same amount of people are passing the tollbooth but the number of vehicles has reduced as the person per vehicle ratio has risen. This hypothetical place becomes polarized over the issue and people are suddenly either a SP (single-person) supporter or a MV (minivan) activist. Political turmoil abounds as debate and discussion stifle change and the issue only becomes more perplexing when someone invents the 4-door sedan.

I imagine that you have only continued to read so far because you are curious what my point is… Well you are in luck. I will likely tell you what I am up to in the next few sentences. Or maybe not. In either case here is a picture of my cat Finnegan as a reward for getting this far.


The hypothetical circumstances I described above are an allegory for the healthcare industry in the U.S. In case you hadn’t guessed it yet, the “multi-person vehicle” is really this newfangled idea I’ve been blabbering on about for the last few months. My point was to illustrate an instance where a complex system was built to function one specific way. This situation can hamper change, and sometimes progress, because the underlying infrastructure is not equipped to adapt. Not necessarily because someone wants it to stay the same but simply because the system has never had to change.

So, if you are still with me here is the whole point (I told you it was coming). Value Based Healthcare is such a profound change from the current way of doing things that the infrastructure and legal framework for healthcare in the U.S. is not completely equipped to handle the change.  In fact, there are a few legal establishments that are barriers to adopting a value-based payment model.  Anti-fraud laws that exist today were designed for a fee-for-service model in a world where doctors often worked for themselves instead of for larger healthcare groups. The Stark Law and the Anti-Kickback law have been specifically indicated by the American Hospital Association as major blockers to the adoption of the value-based initiatives put forth by the MACRA legislation. These laws inhibit hospitals from being able to initiate collaborative and coordinated care for patients without the possibility of legal ramifications. The MACRA legislation even states that the Department of Health and Human Services must make legal exceptions and changes in order to allow for easier pathways to success for new and innovative payment models.

Legal barriers are only one part of the complex landscape that has to be tiptoed through in order for coordinated care partnerships to flourish. The connectivity of systems, equivalent health record formats, as well as organized and consistent billing for each episode of care from both institutional and outpatient providers are all necessary components for a complete VBH system.  While it is easy to put these down in words, it’s not so easy to overcome such hurdles. The reason? The minivan was just invented and not all fuel stations, mechanics or dealers are equipped to handle it.

The takeaway here? If we, as a population, want to make sure that concepts like VBH survive and take hold, we must do what we can to embrace the change. If positive sentiment from patients and legal backing from the government can support each other, more and more providers and payers will make the investment in change. I would say that VBH is already well on its way but even the best-laid plans can fall prey to unstable circumstances. I don’t think that will happen but in my experience it’s always better to be prepared and keep a watchful eye.



Watching from the Wings


Do you ever get the feeling that someone is watching you? If not then I applaud you for your ability to compartmentalize, because someone probably is watching you. No, I don’t mean that neighbor that always seems to be outside when you leave to go to work or that white panel van that sits down the street. I am talking about someone watching the digital wake that follows each of us through our lives.

Whether it is by social media posts, online shopping, internet searches or any number of other online activities, we are generating data all the time that is being harvested and analyzed by huge tech firms. The internet giants use this data to provide value to their platforms and ultimately to customize advertising to each individual user in order to make a profit.

Regardless of your stance about internet privacy and the ethics behind mining what is perceived as personal information, there is a bright spot here. This concept of monitoring and using personal data has been pivoted and transformed into something that we can all benefit from. Insurance companies can use the analytic techniques born in the online world to start driving real change in their provider networks. This can help to reduce their overall cost to operate as well as the premiums they charge for their products.

When it comes to your healthcare data all roads lead to your insurance company. Your primary care provider’s office visits, laboratory claims, prescriptions, and durable medical equipment requisitions all pass through your insurance company. These claims send signals to your insurer about the course of treatment your healthcare providers are administering but until very recently those signals were largely recorded but ignored. Traditionally doctors and other providers would often use one of two methods to prescribe treatment. One was to start with a generic treatment and progressively change that treatment until it became targeted and highly effective for each patient. The other method would be to have a patient go through a barrage of tests to see what, if any, indicators of different conditions would come back in order to then design a specific and effective course of treatment. On paper neither of these seems to be very efficient but, in the end, patients got the treatment they need despite the often times burdensome cost.

I want to be clear that there is nothing implicitly wrong with either of these treatment methods as they can both provide effective care in the long run. That does not mean that there isn’t room for improvement. A bicycle can take me to work every day but a bicycle with a motor can get me there faster and with less effort. Enter modern high-performance and cloud computing services, and a completely new way of administering care comes to light. This would not come without some sacrifice on your part. You would have to let your insurance company keep records of your health information, the care you have received, and the outcomes of your treatment. Would you be comfortable with that?

Imagine, however, you are diagnosed with a relatively common condition. It is nothing overtly serious mind you but will require significant treatment to control. Now, what if your insurance provider has information on thousands of people that have similar symptoms, health history, and are undergoing treatment now? What if your providers could leverage that information to tailor a treatment to you that could not only provide the most effective care, but that ended up saving you and your insurer a lot of money? Are you still uncomfortable? What if you knew that building and using systems like this could dramatically increase the overall health of the public and at the same time reduce healthcare costs overall? Is it worth it?

  • Disclaimer: This Blog is for educational purposes only as well as to provide general information and a general understanding of the topics discussed.  The Blog should not be used as a substitute for legal advice and you are advised to seek additional information from your insurance carriers, Medicare and/or Medicaid agencies for additional criteria and regulations regarding these services.

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