Elroy what's this all about?
Seems GM is in the middle of it somehow
BJC says it will drop United Healthcare
By JUDITH VANDEWATER
Of the Post-Dispatch
03/17/2005
BJC HealthCare said Thursday that it would terminate its contract with UnitedHealthcare this summer. BJC is protesting a pilot insurance plan that snubs most of the doctors in the St. Louis market.
United is one of the area's largest insurers. It has several thousand employer customers and more than 900,000 policy holders in the St. Louis region. BJC is the area's largest health system. It owns or manages 10 hospitals, including Barnes-Jewish Hospital, St. Louis Children's Hospital, Missouri Baptist Medical Center and Christian Hospital.
Both sides say they are willing to continue to negotiate. But if BJC makes good on its threat to cancel the contract Aug. 13, United policy holders will pay much more to use any BJC service, from cancer care to home health services.
Out-of-pocket costs to consumers will vary according to the terms of their respective benefit plans. Some policies require higher deductibles or higher co-pays when beneficiaries elect an out-of-network provider. More restrictive policies may offer no out-of-network coverage.
Steve Walli, president and chief executive of UnitedHealthcare of the Midwest, said, "It is premature to talk about what-ifs." United is in discussions with BJC over the health plan at the core of the dispute, Walli said, and the company was surprised to receive a notice of contract termination Wednesday.
Walli said it is an increasingly common strategy in insurance negotiations for providers to go public with contract termination threats.
Steven Lipstein, BJC's president and chief executive, said the contract termination was an option of last resort. "United forced us to this," he said.
At the core of the dispute is a health insurance program with a small but growing enrollment. The UnitedHealth Performance program is being tested in 13 markets nationwide.
It was introduced in St. Louis last month as a replacement preferred provider organization, or PPO, at General Motors Corp.'s Wentzville plant. GM said about 36 percent of its hourly workers, retirees and dependents are in the Performance plan. Shipper UPS Inc. has 13 Missouri employees on the Performance plan, and it is testing the product in a few other markets.
DaimlerChrysler Corp. will switch its hourly employees and retirees to the Performance plan April 1. Chrysler spokesman Dave Elshoff said the benefit change affects 7,500 United Auto Workers members, retirees and dependents. "Quality and costs are the reasons we are doing this," Elshoff said.
United's Performance program and similar products offered by other large insurers elsewhere are a response to employers' frustration over the inconsistent cost and quality of health care in the face of rapidly rising costs. Large employers are looking for ways to use their buying clout to drive improvements in performance and efficiency.
Walli said the Performance program is the shape of health plans to come. "Our employer customers are demanding programs" like this. "They feel their employees have the right to know which providers are meeting quality metrics," Walli said.
"My hope is that major employers in this market will push back on BJC and others so that programs of this type can work. Employers are telling me they support the methodology and concept," Walli said.
BJC's Lipstein said some employers may opt to reopen their health care benefit enrollment so employees can switch to a health plan that contracts with BJC as an in-network provider. "We have managed care contracts with almost every health plan in the market. I'm of the impression the majority of employers offer multiple options," he said.
"We would certainly regret if this action had any adverse impact on patients," Lipstein said. "We are trying to preserve their access to our programs and our doctors. The United program is trying to deny access to the employees of GM and UPS and Chrysler." Lipstein said BJC will offer service discounts to patients affected by the dissolution of the United contract.
The Performance program is the first in the St. Louis area to attempt to identify providers who excel at quality medicine and cost control. Self-insuring employers set their own benefit design under the plan, but all intend to steer employees to high-value providers.
United crafted the program nationally and rolled it out here at GM in February.
Physicians and health systems here were not involved in the program's design and had no advance notice of its implementation. Many first learned of it from GM workers.
United used its claims data to evaluate providers based on claims filed between Jan. 1, 2002, and Dec. 31, 2003. The review required a physician to have a minimum of 10 claims during that period. That cut out 40 percent of the area's physicians.
Surgeons and other physicians who perform hospital-based procedures were scored on their complication rates. Doctors with office-based practices were assessed on their adherence to best practice standards in the treatment of specific diagnoses. Physicians who met those benchmarks 65 percent of the time were evaluated on economic metrics. Those who met both tests were designated as "star" providers on United's Web site. Patients pay less out-of-pocket when they choose a star provider.
Select specialties, including pediatrics, gastroenterology and dermatology, have not developed clinical quality standards. Doctors in those specialties were measured solely on efficiency. The efficiency formula was complicated.
The rating was based on United's financial liability for all services provided to a patient during treatment for one illness. For example, a physician whose patient was hospitalized after a heart attack would be scored based on the cost of all tests and services provided. Claims were adjusted for severity of illness. To win a "star," the cost score had to be at or below 80 percent of the market average.
[Is this bribery to keep doctors for putting their patients in hospitals or off needed medication?-Mish
Below 80% of average? That's a weird way of putting it isn't it?
.8*.5= .40
You get a star if you are in the bottom 40% on costs.
Of course once people start competing for stars, you have to keep cutting more and more and more costs to maintain your "star rating".
Is that what's going on here or am I missing the boat?
How is GM involved in this mess anyway?
Mish]
Dr. Jordan Ginsburg, medical director of United's St. Louis regional office, said the insurer has since adjusted its criteria to use a more recent data set. That review will add at least 1,500 more providers to the performance roster.
In the original cut, the star designation went to 4,232 providers, or 26 percent, of 16,396 Illinois doctors in the United network and 2,141, or 27 percent of the 7,876 Missouri physicians in the United network.
United also changed its economic evaluation criteria so that doctors who meet average market costs can qualify. It also opened the star program to doctors who have received National Committee for Quality Assurance Recognition.
"Garbage in, garbage
Dr. Al Elbendary, president of the St. Louis Metropolitan Medical Society, said United's program is intended to cut costs. If it identified performance physicians as being cheaper, rather than higher quality, doctors would have no beef, he said.
"What we are opposed to is, they are saying it is a quality measure when they don't have the data to back it up," Elbendary said. "Garbage in and garbage out is the way physicians view this program."
Only four of the 1,144 full-time faculty physicians at Washington University are listed as star providers. These doctors only admit to BJC facilities.
United's evaluation is based on claims by individual doctors. The overwhelming majority of Washington University doctors bill as part of a group or an academic department. Ginsburg said United is working to address this design shortcoming in order to evaluate members of large doctor groups.
Lipstein said that in United's first performance provider list, only 18 percent of academic and community physicians with BJC admitting privileges were identified as stars.
The economic incentives in the program are directed solely at what patients must pay for physician services, but hospitals are affected too. They rely on doctors for all of their patient admissions.
Lipstein said physicians practicing at Barnes-Jewish and Children's hospitals must have academic standing at Washington University. Because of the glitch that prevented the evaluation of Washington University faculty physicians, patients in the Performance program lose virtually any access to Children's and Barnes-Jewish.
Lipstein said BJC asked United to suspend the program. When that failed, BJC asked to work with United in an accelerated attempt to repair the methodology. They were turned down, he said. Next, BJC said it wanted to withdraw as a preferred provider under United's Performance product. United rejected that as well.
"You can't pick and choose what customers can be a part of a contract," Walli said.
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I had to read that 3 times and I still I am not sure I understand it all.
It looks like bribery is only a small part of it.
Let's try this
1) Employers want reduced costs
2) Unlike what the article says they do not give a rat's ass about quality
3) Health care providers said OK we will give you a break in prices (probably a pissy one that will just be hiked next year anyway) in return for major concessions.
4) Part of those major concessions is that people in these plans have to go to "star rated" doctors known to skimp on services rendered
5) According to the article one has to be in the bottom 40% on services rendered to get a star rating
6) One might assume that 40% of the doctors or close to it would be "star rated" but in actuality only 27% or so are "star rated"
7) One hospital chain in particular bills by hospital not doctor so only 4 doctors out of 1000+ get the "gold star"
8) Somehow GM forced this plan on a bunch of people
Now do I have it?
Mish |
