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Kaiser Health News published an article about a researcher finding that private companies are charging Medicare Advantage too much. Medicare Advantage is an innovation that The Centers for Medicare & Medicaid Services (CMS) has been trying out where it pays private insurance companies to insure the care of individuals. In theory, if the private insurers manage the cost of individuals' care more efficiently than Medicare, the private insurers can keep the savings. However, if the private insurers are less efficient, they could lose money. However, some patients are sicker than others, and will therefore need more services. CMS tries to adjust for this by allowing the private insurers to report a risk score, which affects the reimbursement for such patients. Although CMS spells out guidelines for calculating the risk score, the researcher featured in the article believes that private insurers are reporting patients to be sicker than they actually are, costing CMS more than $106 billion from 2010 through 2019.

Kaiser Health News published an article about a researcher finding that private companies are charging Medicare Advantage too much. Medicare Advantage is an innovation that The Centers for Medicare & Medicaid Services (CMS) has been trying out where it pays private insurance companies to insure the care of individuals. In theory, if the private insurers manage the cost of individuals' care more efficiently than Medicare, the private insurers can keep the savings. However, if the private insurers are less efficient, they could lose money. However, some patients are sicker than others, and will therefore need more services. CMS tries to adjust for this by allowing the private insurers to report a risk score, which affects the reimbursement for such patients. Although CMS spells out guidelines for calculating the risk score, the researcher featured in the article believes that private insurers are reporting patients to be sicker than they actually are, costing CMS more than $106 billion from 2010 through 2019.

It's not difficult to imagine that allowing the private insurers to determine the patient risk score is a recipe for higher risk scores (given that the private insurers will get paid more). CMS apparently handles this through audits, but perhaps the frequency and magnitude of the audits are not adequate. It seems like CMS should also be able to study patients that have left Medicare and joined Medicare Advantage to see if a disproportionate number of them end up with a higher risk score compared to patients that have remained on Medicare.

In any case, it seems beneficial for society that CMS has released the relevant data. It remains to be seen whether this research will prompt meaningful change.

Kaiser Health News reported some general statistics about Medicare's Hospital Readmissions Reductions Program (HRRP), which was a program meant to curb unnecessary hospital readmissions by collecting statistics and rewarding top performers while penalizing underperforming hospitals. Hospitals could lose up to a maximum of 3% of their Medicare reimbursements, which can be rather significant given that the typical hospital operates on thin margins. Some good news is that hospital readmissions have declined over the years.

Kaiser Health News reported some general statistics about Medicare's Hospital Readmissions Reductions Program (HRRP), which was a program meant to curb unnecessary hospital readmissions by collecting statistics and rewarding top performers while penalizing underperforming hospitals. Hospitals could lose up to a maximum of 3% of their Medicare reimbursements, which can be rather significant given that the typical hospital operates on thin margins. Some good news is that hospital readmissions have declined over the years.

One figure that sounds rather alarming is that 1,288 hospitals out of the eligible 3,139 hospitals have been punished each of the 10 years of the program. In other words, 41% of the eligible hospitals in this program have never changed their processes enough to avoid the penalty. The high percentage raises the question as to whether the financial penalties should be stronger, or whether some hospitals could benefit from new leadership, or potentially, whether there is something wrong with the rating criteria.

Kaiser Health News published an article where the author detailed her experiences with health care in two different states. In Maryland, the cost of her consultation with a specialist was between $350 to $400 while the same type of appointment in New York was $1,775 (about four times as much). The article recounted some of the author's research into the discrepancy.

Kaiser Health News published an article where the author detailed her experiences with health care in two different states. In Maryland, the cost of her consultation with a specialist was between $350 to $400 while the same type of appointment in New York was $1,775 (about four times as much). The article recounted some of the author's research into the discrepancy.

The background that the article provided is that Maryland set rates for various procedures in the 1970's, and appears to have contained costs better than other states. Apparently, the reimbursement scheme has given hospitals added incentives to encourage active management of patient health so that fewer patients end up in the hospital.

The article also commented that this type of reimbursement structure would be difficult to pull off in other states, in part because of the strong financial position of various hospitals. When Maryland implemented its system, it seems that hospitals experienced a feast-or-famine environment, leading hospitals to be willing to give up some upside gain in exchange for some guaranteed payments. Now, provider networks in other states that do very well financially and can withstand a large degree of uncertainty have much less incentive to limit their downside risk. Increases in health insurance premiums continue to outpace inflation, and at some point, it seems like something will change -- it's just unclear when and how.

Kaiser Health News published an article on what might appear to be an obscure policy battle between Illinois dentists and dental hygienists. At issue is whether or not dental hygienists can perform their work in nursing homes, prisons, and mobile dental vans without the supervision of dentists. Not surprisingly, dental hygienists would like that autonomy whereas the Illinois State Dental Society has argued that "it would be dangerous for hygienists to treat nursing home residents, who are often elderly and sick."

Kaiser Health News published an article on what might appear to be an obscure policy battle between Illinois dentists and dental hygienists. At issue is whether or not dental hygienists can perform their work in nursing homes, prisons, and mobile dental vans without the supervision of dentists. Not surprisingly, dental hygienists would like that autonomy whereas the Illinois State Dental Society has argued that "it would be dangerous for hygienists to treat nursing home residents, who are often elderly and sick."

On the face of it, the position of the state dental society seems ludicrous, especially when their proposed solution is to raise taxes to reimburse dentists at higher rates for seeing Medicaid patients. I suspect Medicaid reimbursement is indeed too low, but the proposed policy does not ask dentists to take on more work for free or reduced payment. The policy question simply expands the venues in which dental hygienists can work without a supervising dentist (which is already allowed in a variety of contexts and in other states). The article quotes a researcher who found that "as dental hygienists gained more autonomy, fewer people had teeth removed because of decay or disease." It seems the burden of proof should be on the dental society that this expansion of autonomy poses a credible safety threat.

It seems that the Illinois State Dental Society may have won this round -- not through research, but through lobbying efforts. From a distant viewpoint, it sure seems like the Illinois State Dental Society favors denying access to useful services for its own financial interests.

Kaiser Health News reported on some health insurance companies that are now offering options that emphasize telehealth visits. In theory, doctors who conduct many virtual visits should be able to save on some overhead, such as not having to staff the receptionist's desk during certain hours. The article discusses at least one organization that specializes in providing doctors who specialize in virtual visits, and who can presumably do so with much less overhead.

Kaiser Health News reported on some health insurance companies that are now offering options that emphasize telehealth visits. In theory, doctors who conduct many virtual visits should be able to save on some overhead, such as not having to staff the receptionist's desk during certain hours. The article discusses at least one organization that specializes in providing doctors who specialize in virtual visits, and who can presumably do so with much less overhead.

Easier access to doctors might also benefit some patients. For example, some patients might respond better to more frequent doctor visits and that could theoretically lead to lower costs for the insurers. It's nice that insurers and providers are trying out alternate business models. Hopefully, some lasting innovations will come from these experiments, even if they end up being different than their current form. It is unfortunate that it seemingly took a major pandemic to prod insurers to explore these options.