Category: Manage Care – Group Health

Nov
10

Discounts and doctors

Posted by Joe Paduda on Wednesday, November 10th, 2004 | Comments

Why do doctors contract with large networks to provide care at a deep discount? Do they expect to get more business from those relationships? If so, does that additional business ever arrive at their examining room? How many other physicians in their area are also contracted with that network? If there are many, are they merely joining to maintain their patient base?
Have they actually done the math to determine the impact of the discount on their finances?
Here’s an admittedly simplistic analysis of the financial impact of a discounted patient visit.

  • The “non-discounted” price would be $100
  • The discount is 20%
  • The net profit on the average patient visit (non-discounted) is 30% (an unreasonably high number, but easier to work with for our purposes)

The doctor makes a profit of $10 per discounted patient visit, and therefore must see three times as many patients to justify that 20% discount. And that’s before one factors in the additional fixed costs associated with the larger patient load – more parking, more staff, a larger waiting room, more examining rooms, and more of his/her professional time.
Perhaps more physicians are “doing the math”, and that is why managed care firms are having a much tougher time getting discounts.
The network deep discount model has other fundamental flaws, flaws that are only now beginning to be fully appreciated.

Nov
9

Anthem-Wellpoint merger

Posted by Joe Paduda on Tuesday, November 9th, 2004 | Comments

It looks like the Anthem-Wellpoint merger is going to go through after all. John Garamendi, the Insurance Commissioner of California, was holding up the merger, claiming it would cost California’s members in both dollars and health care quality.
Garamendi successfully negotiated with the merger parties, getting them to provide over $100 million in payments to fund rural health, child health, nurse training, and other initiatives. In addition, Anthem-Wellpoint promised to not raise CA premiums to pay for the merger; the actual language mentioned that the entity will not pass along merger costs to Blue Cross (Anthem) customers in CA.
This is exactly what we had predicted would occur; the only surprise is it took longer to get the deal done than I thought.
What does that mean? Maybe something, perhaps not much. There are any number of reasons for premium increases, and lots of ways to change premiums that could be used to “hide” merger-associated costs. These could include:
–plan design changes
–different provider panels
–amortization of capital expenses
–different risk pooling
–increased distribution expenses
— and on and on.
The net is this – Garamendi got some additional concessions, the “rate increase” deal is probably unenforceable, and he, and Anthem-Wellpoint, can move on to other priorities. For Garamendi, it may likely be contingent commissions, sham-bidding, and other broker-consultant games. Your author’s opinion is this elected official can’t stand to be upstaged by another regulator, and Mr. Spitzer’s press is likely driving Mr. Garamendi nuts.
While Anthem and Wellpoint are free to move on, brokers, agents, et al are likely to feel the “wrath of a regulator scorned.”

Nov
9

Rewarding the “right” providers

Posted by Joe Paduda on Tuesday, November 9th, 2004 | Comments

The Piper Report, a well-respected weblog focused on all issues healthcare, published a great piece about techniques for encouraging enrollment in high-quality health plans.
Briefly, the piece documents the success some states see when they use “performance based auto-assignment”. This is engineer-ese for enrolling people in health plans based on the performance of the plan. States practicing “PBAA” (my acronym, not their’s) assign Medicaid recipients to health plans based on a comprehensive analysis of plans’ performance – quality, cost, access, patient satisfaction may be used in this analysis. This assignment only occurs if the recipient has not picked their own plan within the required time frame.
“PBAA” is being extended to Medicare prescription drug beneficiaris, in January of 2006. The first of that year, over 7 million Medicare recipients will find themselves participating in prescription drug “auto-assignment”.
There will be clear winners and losers, but among the winners will be taxpayers and beneficiaries. No topic has generated more heat and less light than the issue of “pay for performance” – here is the best example to date of why performance matters.
Perhaps employers should consider employing the same method in selecting health plans for those workers who can’t seem to enroll on time…

Nov
8

One reason California hospital costs are rapidly increasing

Posted by Joe Paduda on Monday, November 8th, 2004 | Comments

Hospital costs are among the key drivers of medical inflation. In turn, one of the largest components of hospital costs is labor.
What may not be “new news” to many is the nationwide nursing shortage. This shortage is leading to closure of wings or departments, hospitals raiding each other for staff, importation of nurses from the Phillipines and other countries, and chronic overtime for the majority of nurses.
Nowhere is this shortage more acute than California, where the “rock” of the RN shortage has run into the “hard place” of the law. A 2003 California law requires all hospitals to maintain a staffing ratio of one nurse to each eight patients. It further limits the number of vocational nurses, and prohibits all but RNs from caring for critical trauma patients. That’s today.
California’s nursing shortage
In less than two months, hospitals will have to staff at a 1-to-5 standard. However, regulators are asking for, and will likely receive, a delay till 2008 for implementation of that standard. This looks like a foregone conclusion, which is certainly appropriate as many hospitals can’t meet the standard today. In fact, according to a piece on the California nursing shortage in California Healthline,
“A California Healthcare Association survey found that 85% of hospitals do not comply with the regulations, and a California Nurses’ Association survey found that 42% not do comply. ”
Here’s the link. Penalties for non-compliance are significant, and will likely be enforced with more alacrity in coming months. With state laws mandating more nurses, and few nurses to be found, the price elasticity rules of economics will come into play. Big demand for few nurses mean all nurses will make more money – probably a lot more.
The result – higher hospital costs in California, and, short of importing nurses, little any managed care firm, insurer, or employer can do about it.

Nov
8

First Health and Coventry

Posted by Joe Paduda on Monday, November 8th, 2004 | Comments

The latest information on the Coventry acquisition of First Health may provide a sense for the future of the merged entity.
Item 1.
Profits at First Health are down, ostensibly due to “merger related charges” and steep declines in revenues from FH’s MailHandler’s employee benefit program.
The MailHandler’s program is a federal employee health benefit plan, formerly administered by CNA Insurance. Several years ago FH won the contract, taking it from CNA (who happened to be a FH customer at the time). It accounts for a significant portion of FH’s topline (revenue).
Item 2.
Coventry EVP Tom McDonough has been named to oversee the integration of FH and Coventry. McDonough joined Coventry from UnitedHealthGroup, where he was responsible for their large, multi-state employer groups. Clearly, this experience is highly relevant to FH’s present market mix.
Item 3.
Several years ago, UnitedHealthCare divested itself of its’ Workers’ Comp entities, specifically Focus Healthcare and MetraComp, after the MetraHealth acquisition. McDonough was at United at the time, as were other current Coventry executives (e.g. Harve DeMovick, now CIO).
Item 4.
Coventry and FH stock prices have not fared well since the acquisition announcement. The Motley Fool, long a critical observer of FH management, had this to say just after the announcement:
“No sooner had the buyout news gone out than 11% of Coventry’s market capitalization vanished, and McGraw-Hill’s (NYSE: MHP) Standard & Poor’s placed Coventry on its watchlist for a possible debt-rating downgrade. The reason: Coventry may be overpaying for this underperforming business. Coventry plans to pay for its purchase roughly half in stock (at a 0.1791:1 exchange rate) and half in cash ($9.375 per share of First Health). At Coventry’s Wednesday closing price, that would value First Health at $18.75 per share, imputing a valuation of $1.7 billion to First Health. Factoring in Coventry’s own share price decline in response to the deal’s announcement, however, brings the agreed value of First Health shares down closer to yesterday’s close — about $17.70.”
Currently, Coventry’s stock price remains significantly below the pre-acquisition level (from $53.50 to $44.01 today). I doubt either Coventry or FH management are terribly pleased with this…
One of the criticisms advanced by analysts is the potential for Coventry management (which is highly respected) to become distracted by the merger and the non-core FH business – PPO, Workers’ Comp, etc.
Net is this – if the Coventry stock price continues to languish, expect to see a “return to the core” – perhaps spinoff of some of the non-core assets.