Value-Based Insurance

“If patients insist on medical procedures that science shows to be ineffective or unnecessary, they’ll have to pay for all or most of the cost.”

We all “demand” tests and prescriptions from out doctors and it is often easier for them to comply than argue. Now there may be a price to pay.

The Reuters article reported on “value-based” insurance with this vignette:

“When Tanner Martin, 17, developed excruciating back pain last year, he was sure he needed an X-ray to find out what was wrong. So was his mother, who worried that the pain might indicate a serious injury that could cause permanent disability.”

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“Under REFERENCE PRICING the Employer or Insurer Sets a Maximum Contribution … Toward the Payment for a Test or Treatment.”

The Wall Street Journal explored the health care insurance concept of Reference Pricing.

“The employee or enrollee can select any hospital or clinic but must pay the difference between the contribution limit and the actual price.”

“Reference pricing serves as a reverse deductible. Rather than the patient paying up to a defined limit and then the insurer covering the remainder, the insurer pays up to a defined limit and the patient pays the remainder. This has the remarkable feature of exposing the patient to the variation in prices for treatments that are above deductible thresholds. And the patient’s contribution isn’t limited by an annual out-of-pocket maximum.”

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“…the Out-of-Pocket Limit Doesn’t Exactly Live up to Its Name.”

The LATimes vignette noted “My coverage from Blue Cross Blue Shield of Illinois is exempt from the new limits because it predates the ACA, but it still has annual spending caps. The limits are $10,000 for services by providers in the plan’s network and $20,000 for out-of-network services. As a Blue Cross Blue Shield representative patiently explained to me, however, the out-of-network limit isn’t really a limit. When a customer reaches that amount, the insurer will still pay only the standard out-of-network share. That’s why my plan covered only 50% of the $54,755 charged by Tristate Care Flight to ferry me (by helicopter) from a car wreck in Quartzsite, Ariz., to a hospital in Phoenix. If Tristate wanted to bill me for the other half, the representative explained, it was free to do so.

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“…Unnecessary Medical Tests and Procedures Is a Serious Problem…”

The Robert Wood Johnson Foundation article noted: “three out of four U.S. physicians say the frequency with which doctors order but just as many say that the average physician orders unnecessary medical tests and procedures at least once a week…”

“…half of physicians think they are in the best position to address the problem and have ultimate responsibility for making sure patients avoid unnecessary care. Yet at the same time, more than half the physicians surveyed say they’d give an insistent patient a medical test they knew to be unnecessary.”

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“One in Four Medicare Patients Got Medical Care That Provided No Benefit at a Total Cost of at Least $1.9 Billion…”

The Modern Healthcare article noted “overuse for more than two dozen cancer screening, imaging, diagnostic, preventive or preoperative testing services and found it totaled 0.6% of Medicare spending.”

“The results underscore the potential for savings from efforts to eliminate medical care that has been identified by previous research as unnecessary, and wasteful, such as colorectal screening among those age 85 and older with no history of colon cancer.”

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“…Health Care News Stories Often Emphasize or Exaggerate Potential Benefits, Minimize or Ignore Potential Harms, and Ignore Cost Issues.”

The JAMA Internal Medicine article included the following abstract “From April 16, 2006, through May 30, 2013, a team of reviewers from HealthNewsReview.org, many of whom were physicians, evaluated the reporting by US news organizations on new medical treatments, tests, products, and procedures. After reviewing 1889 stories … the reviewers graded most stories unsatisfactory on 5 of 10 review criteria: costs, benefits, harms, quality of the evidence, and comparison of the new approach with alternatives. Drugs, medical devices, and other interventions were usually portrayed positively; potential harms were minimized, and costs were ignored. Our findings can help journalists improve their news stories and help physicians and the public better understand the strengths and weaknesses of news media coverage of medical and health topics.”

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Unnecessary Tests and Procedures in the Health Care System

The Choosing Wisely article noted “Physicians Say Unnecessary Tests and Procedures Are a Serious Problem, and Feel a Responsibility to Address the Issue.”

“Physicians say unnecessary tests and procedures represent a serious problem in the health care system. A majority of physicians feels a strong responsibility to help their patients avoid unnecessary care.”

“84 percent of physicians are interested in learning more about evidence-based recommendations that address when tests and procedures may be unnecessary. Physicians with exposure to the Choosing Wisely campaign are 17 points more likely to have reduced the number of tests or procedures they have done in the last 12 months. 45 percent of primary care physicians say they have seen or heard about the Choosing Wisely campaign after a description.”

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“…Physicians Believe That Fellow Doctors Prescribe an Unnecessary Test or Procedure…”

The Kaiser Health News article noted “The most frequent reasons that physicians order extraneous—and costly—medical care are fears of being sued, impulses to be extra careful and desires to reassure their own assessments of the patient…”

“… Choosing Wisely, a two-year old campaign devised by a foundation created by internal medicine doctors … has persuaded nearly 60 medical societies to identify overused tests and procedures. The goal is to cut back on needless medical care, which by some estimates may waste a third of the $2.8 trillion the country spends on health each year.”

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Hospital Runs Ad for $1,995 Colonoscopies in Sunday Newspaper

The Becker Hospital Review article reported “A hospital in New Hampshire is garnering some attention after it advertised its colonoscopies for a flat rate in the Sunday newspaper.”

“Elliot Hospital in Manchester, N.H., is using CareBundles to set all-inclusive fees for colonoscopies, hernia repair ($4,995) and knee arthroscopy ($5,995), according to a New Hampshire Public Radio report. Only the uninsured can get these set-price procedures for now, although the hospital is hoping to launch relationships with employers.”

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“Incidentalomas” + – Concerns about Overdiagnosing and Overtreating Cancer

The Wall Street Journal article noted “Removing the word ‘cancer’ from the terminology used for many slow-growing lesions in the breast, prostate, lung, skin and other body areas could ease patients’ fears and reduce the inclination of doctors to treat them aggressively, says a panel of experts advising the National Cancer Institute.”

“…new diagnostic technology is finding ever smaller abnormalities that are unlikely to be lethal, but are being labeled cancer and treated as if they were. The result: billions of dollars in unnecessary surgery, radiation and chemotherapy.”

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