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Who wins with the current approach? No one! This reinforces my belief that all of us, including the largest federal health care agency, have forgotten that the primary reason for providing managed Medicare benefits, quality care with expanded benefits at an affordable price, is the patient. As each Medicare MCO has to look internally and consider its commitment, convictions and conscience in abandoning the elder portion of our population, so should HCFA look within to make cost-cutting changes — changes that allow for appropriate reimbursement and are managed by experts who know how to provide access to quality care and pay attention to cost centers.
Just as the Bill of Rights confirms certain inalienable choices for each citizen, so should there be the unqualified opportunity to live each day, in wellness and health, without fear of bureaucratic runarounds or restrictions that become barriers to needed medical care.
Will we be any better off when the Medicare+Choice program is a forgotten memory? When patients are left with fee-for-service Medicare for which they must buy expensive and non-comprehensive supplements, forego preventive and wellness benefits and coordinated services, and face the decision of whether to eat or get needed treatment? I don't think so, and both political parties and the executive federal bureaucracy should be ashamed.
One Company's Stand
Venture Health Partnership Group (VHPG) is a new company, dedicated to reforming the managed care industry with actions, honesty, and service. Our two plans have participated in the Medicare+Choice program for many years, providing services to some 33,000 enrollees. We have chosen to stay in this program, even at the risk of severe financial losses next year, while HCFA and the leadership of the Republican and Democratic parties offer strident rhetoric but no real solutions. Why? Because I believe it is unconscionable to abandon this segment of the population when we have worked so hard to educate them, and when they have begun to recognize the value of a coordinated approach to health care services without huge out-of-pocket expenditures or financial uncertainty. We are standing our ground, optimistic that the marketplace, if not the regulators, will recognize the difference between a Wall Street-driven approach to health care and a community-based one. Perhaps I'm being naive, but we have to take a stand and start somewhere.
"Dirty Dozen" Solutions
I have twelve recommendations to streamline the fiscal and care efficiency practices that senior consumers need and deserve. When implemented, these recommendations will afford the practitioner the right to practice reasonable medicine without mindless constraints and the MCO the ability to sell health benefits that are affordable and appropriately reimbursable to cover medical costs. They will impact all areas of health care delivery by reducing duplication and costs. I call them the Dirty Dozen.
1. Create an unbiased National Ethics Standards Board that will review and accredit the fairness processes related to accessibility, authorization, referral and denial of care, as well as the adjudication procedure for coverage determination. This federal board, which will set the standards for reviews, is a less costly and less controversial alternative than current approaches, and should be comprised of representatives from clinical medicine, business, and consumers. The board would be the forerunner of an established national standards board that would certify the validity of the practice guidelines used by health plans to determine medical necessity.
Advantage: A National Ethics Standards Board will reduce the managed care backlash by certifying the independence of the review processes rather than by imposing legal liability on MCOs and insurers. It will also create objective standards as a basis for all medical reviews that would offset the increasing number of denials related to the subjective analysis of medical necessity. Most importantly, it will go a long way toward restoring credibility in the health care and insurance businesses to a highly disgruntled consumer electorate.
2. Establish a two-year blue ribbon commission charged with creating realistic, practical applications to streamline, consolidate, and unify regulatory agencies and reporting requirements connected with federal health administration, including HCFA, the Office of Inspector General (OIG), the Federal Employee Health Benefits Program (FEHBP), and all other agencies that oversee, administer, or regulate health care programs. This commission would include representatives of all federal agencies that have health care components and would be mandated to reduce or eliminate at least 20% of the regulatory and oversight costs in this arena. The resulting streamlining commission could then become a standing health care watchdog agency with a consumer orientation.
Advantage: The commission would increase government efficiency and productivity, integrate agencies through the consolidation of information and functions, and obviously reduce associated costs.
3. In concert with the above recommendation, unify all current accrediting agencies and develop a single set of credentialing standards. Require Medicaid, Medicare, the Department of Defense (DoD), the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and American Accreditation HealthCare Commission (URAC) to develop one common set of standards which would be used annually for all health care facilities and agencies, both public and private.
Advantage: The unification of all accrediting agencies would create objective, rather than subjective, standards by which all health care agencies could be judged in relation to quality and efficiency, and, in so doing, would reduce costs, bureaucracy, and duplication.
4. Institute the following standards to increase the operating efficiency of health delivery systems and reduce unnecessary paperwork:
Establish national standards for administrative costs borne by administrative, operational and managerial structures to best focus dollars on services, not infrastructure.
Develop guidelines for multiple coverage and insurer responsibility, invisible to providers and patients, for which insurers are responsible in terms of benefits, portability, and lapses in coverage.
Establish uniform data set standards for electronic claims adjudication that include: - Patient information elements
- Medical records requirements
- Claims and billing elements
- Reporting requirements to government agencies
These measures should be combined with a requirement to assess a manual adjudication fee on any non-electronic claims adjudication that payers still utilize.
Advantage: This simplification and unification of administrative operations will reduce costs and increase efficiency. Using electronic claims adjudication would also streamline administration at all levels and reduce provider dissatisfaction with the lack of integrity shown by health insurers in terms of time-liness and accuracy of payment.
5. Advocate for the repeal of the Employee Retirement Income Security Act (ERISA) exemptions (self-insured plans need to be regulated to avoid the practice of cost shifting and reduction of benefits) and the substitution of a state-mandated benefits law that requires uniform mandated benefits for insured and self-insured plans.
Advantage: The current argument that large employers will simply drop health coverage if ERISA is repealed can be offset by the proposal of legislation requiring employers of more than 500 employees to offer a minimum standardized health benefits package with at least a 50% employer contribution.
6. Encourage the creation of an employer tax credit for those businesses that include financial incentives in their health care benefits plans relating to the promotion of and payment for wellness initiatives.
Advantage: The employer tax credit would serve to promote education and the use of wellness strategies such as fitness centers, smoking cessation programs, alcohol and drug education, immunizations, and weight and stress reduction programs. This would reduce health benefit usage as it relates to treatment of chronic disease, and would encourage disease man-agement and implementation of preventive medicine tools, thereby decreasing costs related to utilization.
7. Revise or rebuild all publicly funded health care delivery systems to include national standards, simplify infrastructure and administration, as well as clarify purpose and improve provided health care. Merge all DoD health personnel and facilities, including the Veterans Administration facilities, into a united system delivering health care. Permit public access to these systems, and support and provide incentives for commercial insurers to contract with these facilities/systems.
Advantage: This delivery system revision would reduce federal costs and eliminate under-utilization of services and facilities.
8. Establish a drug benefit mandate that must be offered by all Medicare supplemental insurers and MCOs and that must incorporate an established and mandated national formulary.
Advantage: A mandated drug benefits program for Medicare beneficiaries is the only way to place price controls on drugs through their inclusion in implemented formularies.
9. Stimulate Health Insurance Purchasing Cooperative (HIPC) programs through the provision of state block grants to encourage the formation of state-sponsored purchasing coalitions for aggregation of small business health insurance products into large risk groups that would be competitively marketed to insurers and MCOs.
Advantage: Most traditional approved and supported coalition efforts of this type have failed due to lack of funding and market mandates. Support through the use of sponsorship and incentives would assure the success of this mandate.
10. Evaluate the creation of a federal subsidized program to establish insurance coverage for the un- and under-insured rather than continuing to rely on state mechanisms supporting reimbursements with federally matching funds and subsidization of bad debt and free care by hospitals. Health insurers would be required to provide policies for the un- and under-insured equivalent to 10% of commercially enrolled lives.
Advantage: This initiative would shift the focus of caring for the un- and under-insured to the commercial market which is better equipped to market and deliver care to this population, rather than having it managed indirectly by hospitals under their Medicare, Medicaid, bad debt and free care allowances.
11. Evaluate the feasibility of creating a National Medicaid Benefits Program in which all commercial insurers and MCOs would be required to participate.
Advantage: Complex federal/state/Medicaid partnerships comprising the Medicaid program have resulted in increasing abandonment of private Medicaid initiatives and reliance on varying levels of coverage benefits and the bureaucracy of state Medicaid plans.
12. Support legislation to create medical savings accounts (MSAs), allowing consumers to purchase supplemental and non-covered health benefits that would be tax deductible.
Advantage: The MSA concept is sputtering under conflicting and restrictive state regulation and requires federal standardization and support.
It is time for all of us to stand up and deliver, even, and perhaps especially, HCFA. |
