Self-dealing between a health system and its insurance company

Just when you think you've seen the limits of market power, creativity emerges.  Julie Donnelly at the Boston Business Journal reports:

Partners HealthCare aims to drive new members to its newly acquired health insurer, Neighborhood Health Plan, by cutting off access to some doctors within new health plans offered under ObamaCare.

Neighborhood Health Plan is one of 10 insurers that has been certified to offer subsidized and un-subsidized ObamaCare plans through the state’s Health Connector.

But what Neighborhood Health Plan has is exclusive access to primary-care doctors at Brigham and Women’s Hospital and Massachusetts General Hospital.

Now that Partners, the parent organization of the Brigham and Mass General, owns a piece of the insurance pie, they have decided to offer access to their primary care doctors only to those members who choose Neighborhood Health Plan.

This is likely to drive new business to Neighborhood Health Plan from Boston-area patients who want to keep or begin a relationship with a primary-care doctor at one of the two most prestigious hospitals in the state.
 
This is a departure from Partners’ strategy in the past. Before its purchase of Neighborhood Health Plan, Partners’ offered access to its doctors to all of the health plans within the state-subsidized health plans that were launched under Massachusetts' own statewide health reform.

Dear GBIO, No need for your meeting

Sometimes, the concatenation of news stories on the same day is too compelling to pass by.

On Wednesday, the Boston Globe reported:

The next big movement in Massachusetts health care may come not from the state’s world-famous hospitals or its cutting-edge research labs, but from houses of worship. Stepping up pressure on the health care industry to control spiraling costs, which are crimping family and government budgets, the Greater Boston Interfaith Organization will host a forum next Tuesday at Temple Israel in Boston’s Longwood Medical Area to grill hospital and insurance leaders about the affordability of medical care.

On the same day, with no hint of irony, the same newspaper reported:

Public health officials on Wednesday approved Brigham and Women’s Hospital’s proposed $450 million research and outpatient center, deciding that the project will allow the hospital to better care for patients.

(See more about this in a post I published in December 2011.)

Meanwhile, over at the Boston Business Journal, we read:

Boston Children’s Hospital . . .  said net patient revenue totaled $236.9 million in the three months that ended June 30, a 5 percent year-over-year increase driven by greater demand for outpatient services as well as several initiatives to boost revenue through “enhancement initiatives.”

The Patriot Ledger brings this to the personal level by explaining how individuals can be hurt by the current Medicare rules, which allow hospitals very little discretion about defining admission versus observation status:

Ann Gillis of Milton, who is 83, is fighting the denial her appeal of a $7,000 bill she faced for follow-up rehab services after being hospitalized at Beth Israel Deaconess-Milton last winter. The problem: she was placed on observation status rather than admitted to the hospital, even though she was in the hospital four days. Not being admitted meant Medicare wouldn't cover her rehab at follow-up skilled nursing care in Westwood.

And when research might help produce savings, WBUR tells us:

The Framingham Heart Study is considered one of the most important research projects in medical history. Over the last 65 years, data from the study has been used to develop and test technologies and treatments that have saved millions of lives and hundreds of billions of dollars in health care costs. But now, the mandated across-the-board budget cuts, known as the sequester, are dramatically reducing federal funding for the research.

So, GBIO, what is it you hope to learn at your meeting that isn't being splayed out in the daily media?

Coach gets failing grade in concussion training

Our state youth soccer association now requires all coaches to take an on-line training session (like this one from the CDC) about concussions.  This is a good thing because concussions of boys and girls can be serious, especially if the child is prematurely permitted to play and experiences a second one.  Here's the policy:

The Massachusetts Youth Soccer policy on concussions is intended to be clear and unambiguous so as to accurately reflect the seriousness of concussion-related injuries and our unwavering commitment to keeping our children safe.

A player removed from participation as a result of a head injury or symptoms similar to those of a concussion shall not be permitted to return to play to any extent until they have provided their team coach with a written unconditional “Medical Clearance to Return to Play” from a licensed Medical Doctor.

It is our expectation that this policy will clarify protective measures for all involved in youth soccer in Massachusetts and simplify communication between coaches and parents when concussion related issues arise. 

The training and policy are supposed to make it easy for a coach.  If the child is disoriented or dizzy following a head injury, or experiences several other symptoms (see below), we pull them off the field for the duration of the game.  Referees are likewise instructed to enforce this policy.

Today, when refereeing an under-14 boys game, after a collision in front of the goal, the goalkeeper started to walk off the field complaining of a head injury and dizziness.  Imagine my surprise when the coach came out onto the field and started to try to convince the boy that it was "not a very hard hit."  I intervened and said that he would have to leave the field.

The replacement goalie was excellent and made some terrific saves.  Nonetheless, the coach tried to replace him 15 or 20 minutes later.  I was some distance away and didn't recognize it as the same boy who had been injured, but my assistant referee, a high school boy, did.  He came running out to inform me and to make the point that the boy was not permitted back on the field absent medical approval.  Of course, we sent him back to the sidelines.  Who knows what kind of persuasion the coach had used on the sidelines to encourage the boy to re-enter the field?

After the game, in front of the other AR, I praised my AR for his good judgment.  He said, "I've had a concussion, and I don't want anyone to go through what I did."

Indeed.  It's time for the coach to retake the course.

Having their cake and eating it: Perverse incentives

A friend made an excellent point the other day, upon reading my post about Consumers Union's advocacy for warranties on orthopaedic devices.

"The thing about CU and the warranty struck me hard as a revelation. We in the health care field are brainwashed into thinking these normal business practices shouldn't apply to medicine, while embracing the idea that the money-making business ideas (like ROI) should apply. But basically it adds up to doctors, administrators, and equipment suppliers having their cake and eating it, too: Getting to apply the positives from business, while avoiding the negatives which apply in all other industries, like guarantees of your work."

The big costly examples are obvious:  An alliance among the three groups (doctors, administrators, and equipment suppliers) to install a surgical robot or a proton beam machine to gain market share, but take no responsibility for determining clinical efficacy or adverse impacts or overall inflation of medical costs.

But as my friend points out, the small, ongoing ones are equally obvious.  Orthopaedic devices that regularly fail after installation in human bodies, with no recourse to the suppliers, and no adverse consequences for the hospitals or doctors that have used them without insisting on warranties.  Ditto for minimally invasive surgical equipment, which is notorious for failing after normal cleaning and sterilization processes.

You would think that the payers--Medicare, Medicaid, and private insurers--would step in, but they are complicit or oblivious.  You would think that the group purchasing organizations would step in, but they, too, are complicit or oblivious.  Maybe they are motivated by the implicit or explicit kick-backs they get by favoring certain suppliers.

On the road with WIHI

The next WIHI broadcast — On the (Virtual) Road with Mobile Clinics and Population Health — will take place on Thursday, September 12, from 2 to 3 PM ET.

Our guests will include:

• Nancy Oriol, MD, Dean of Students, Harvard Medical School; Co-Principal Investigator, Mobile Health Map; Co-Founder, Family Van, Boston, MA
• Leonel Lacayo, MD, Gastroenterologist, Glenwood Hospital; Co-Founder, Health Hut, Ruston, LA
• Anthony Vavasis, MD, Director of Medicine, Callen-Lorde Community Health Center, New York City, NY; Co-Principal Investigator, Mobile Health Map
• Jennifer Bennet, BA, Executive Director, Family Van and Mobile Health Map
• Niñon Lewis, MS, Director, Triple Aim Initiatives, Institute for Healthcare Improvement, Cambridge, MA

What’s the first thing that comes to mind when you spot a mobile health clinic? Good people, probably volunteering their time, traveling to underserved neighborhoods to offer screenings, health education, and some helpful, friendly guidance on where to go for anything more serious or chronic that should be checked out? If this is your impression, it’s fairly accurate. Except for one thing. Nowadays, more and more mobile health vans are an integral part of the health care system… especially in cities and communities where traditional bricks-and-mortar health care services are linking up with innovative community outreach programs that, together, can better manage population health. 

With that as a backdrop, we’re going to hit the (virtual) road on the September 12 WIHI with some of the leading innovators and researchers who are injecting new fuel and purpose into more than 2,000 mobile health clinics across the US. They’re doing this by mapping what’s taking place at a range of health clinics mounted on wheels, and also by carefully investigating health issues that can be impacted and maybe even better addressed by a mobile health van.

If we’re serious about improving population health, it’s critical to look hard at what’s already “out there” that’s working or helping, and then determine how to strengthen its role. Mobile health clinics are increasingly one such trusted and effective resource in many communities. WIHI host Madge Kaplan and IHI’s Niñon Lewis invite you to find out the latest on mobile clinics from an expert panel of clinicians and researchers on the forefront of the issue.

You can enroll for the broadcast here.