Understanding the Issues 2008: Health Care

[dmek25]

schneed, its funny you mention the companies blue cross and aetna. from 1999 until 2006, i had blue cross, that was company provided. last year our company switched to aetna. i never thought that much about it until i got a phone call from my brother. he said aetna is the worst. refuses to pay on just about everything. this year our company switched back. one of the big wheels wives got really sick. and aetna fought them tooth and nail over everything. thus the switch. you talk about compensating providers based on quality. in theory, this is a great idea. in reality, who makes this call? or is this another way for some one to make a ton of money for giving good marks to some providers that don't really deserve it? if its someone involved in the insurance industry that will be doing the grading, it definitely isn't going to work

[Schneed10]

Originally Posted by dmek25

schneed, its funny you mention the companies blue cross and aetna. from 1999 until 2006, i had blue cross, that was company provided. last year our company switched to aetna. i never thought that much about it until i got a phone call from my brother. he said aetna is the worst. refuses to pay on just about everything. this year our company switched back. one of the big wheels wives got really sick. and aetna fought them tooth and nail over everything. thus the switch. you talk about compensating providers based on quality. in theory, this is a great idea. in reality, who makes this call? or is this another way for some one to make a ton of money for giving good marks to some providers that don't really deserve it? if its someone involved in the insurance industry that will be doing the grading, it definitely isn't going to work

Dmek, with all due respect, you apparently know nothing on how pay for performance works. Quality is not "judged" or "graded" by someone who comes in and peeks under the hood of your hospital. It is judged by hard numbers standardized within the industry:

- % of people dying compared to the expected death rate
- % of patients receiving unplanned return to surgery
- % of patients discharged within a predetermined time frame appropriate for their illness

You either meet those numbers or you don't, it's not subjective. If you meet them, IBC and Aetna give you a 5% increase on your reimbursement rates next year. If you fail, they only give you a 2% increase. Cut and dry. It's widely regarded as one of the best innovations to come about in healthcare reimbursement recently.

[dmek25]

Originally Posted by Schneed10

Dmek, with all due respect, you apparently know nothing on how pay for performance works. Quality is not "judged" or "graded" by someone who comes in and peeks under the hood of your hospital. It is judged by hard numbers standardized within the industry:

- % of people dying compared to the expected death rate
- % of patients receiving unplanned return to surgery
- % of patients discharged within a predetermined time frame appropriate for their illness

You either meet those numbers or you don't, it's not subjective. If you meet them, IBC and Aetna give you a 5% increase on your reimbursement rates next year. If you fail, they only give you a 2% increase. Cut and dry. It's widely regarded as one of the best innovations to come about in healthcare reimbursement recently.

this is where the issue is. you have to meet certain " goals " to get the reimbursement. if this happens, there will be an accountant in every hospital in charge of the numbers. those numbers will be scrutinized over and over again to make the " goal " you probably know as well as i do that anyone can make numbers look and say anything that they want. im lucky. i have a top 25 hospital right here in my home town. i have access to some of the very best care available.

[Schneed10]

Originally Posted by dmek25

this is where the issue is. you have to meet certain " goals " to get the reimbursement. if this happens, there will be an accountant in every hospital in charge of the numbers. those numbers will be scrutinized over and over again to make the " goal " you probably know as well as i do that anyone can make numbers look and say anything that they want. im lucky. i have a top 25 hospital right here in my home town. i have access to some of the very best care available.

Incorrect. You have to report the numbers to the government via the Medicare Cost Report, and are subject to an annual audit. Allegheny (a former Philadelphia hospital group since taken over by Tenet) got themselves into a lot of hot water when they fudged some reimbursement documents in the 1990s. They were fined a crapload of money which weakened their balance sheet, and they were eventually taken over by Tenet.

It doesn't pay to fudge those kinds of numbers.