Not so long ago there was a time when unconventional treatments—alternative modalities of care—were dismissed by the traditional medical community as being incorrectly presented to patients as scientific. Such methods were deemed to be pseudoscience. Only recently have insurance companies allowed reimbursement for some alternative practices because they didn’t want to miss out on the money patients were spending elsewhere.
Chasing bigger profits, the insurance cartel has now come full circle to embrace pseudoscience wholeheartedly. From deep inside the inner workings of the giant insurance companies comes the very antithesis of fact-based statistics and research: Value-Based Care. Though the concept has been brewing for more than a decade, it’s now hitting the mainstream as the darling for determining how medicine and money will be dispensed. This impressive sounding term essentially justifies the biggest rip-off of all time.
Santa Fe, New Mexico, 16 July 2015
By TAMMM Staff
Government Tools and Their Lofty Promises: Live or Die Based On Industry-Speak
We are going to be discussing four terms to get your heads wrapped around:
- Electronic Health Records
- Evidence-Based Medicine
- Value-Based Care
- Bundled Payments
To spare all of us the agony of reading their annoying acronyms while attempting to figure out their various forms, we’ve built this handy chart:
|Electronic Medical Records||Contains the standard medical and clinical data gathered in one provider’s office.|
|Electronic Health Records||Goes beyond the data collected in the provider’s office and includes a more comprehensive patient history.|
|Evidence-Based Medicine||Aims to optimize decision-making by emphasizing the use of evidence from well-designed and conducted research.|
|Value-Based Medicine||The theory and practice of effective healthcare decision-making for situations in which legitimately different (and hence potentially conflicting) value perspectives are in play.|
|Value-Based Care||A way of addressing the variation in the fee-for-service model of reimbursing healthcare providers by employing evidence-based medicine and proven treatments and techniques that take into account the patients’ wishes and preferences.|
|Values-Based Practice||A provider or care facility that implements value-based care by linking science with the unique values of the particular people involved (as clinicians, patients, care givers and others) in a given clinical decision.|
|Value-Based Services||Where a portion of the provider’s total potential payment is tied to a provider’s performance on cost-efficiency and quality performance measures. While providers may still be paid fee-for-service for a portion of their payments, they may also be paid a bonus or have payments withheld. For value-based contracts, this bonus is not paid unless the provider meets cost efficiency and/or quality targets.|
|Value-Based Insurance Design||Used to incentivize beneficiaries with specific health conditions to use high-value (high-quality, low-cost) health care services and/or providers.|
|Value-Based Purchasing||Assesses the performance of participating facilities based on selected quality measures and makes incentive payment awards to facilities that perform the best or improve the most in terms of quality.|
|Episode-Based Payments||Calculated by the length of time that is covered (i.e., a hospital stay plus aftercare for one year) and the range of providers and services that are included (i.e., primary care and specialists, devices, drugs, facilities).|
|Bundled Payments||Defined as the reimbursement of health care providers (such as hospitals and physicians) on the basis of expected costs for clinically-defined episodes of care. Also known as episode-based payment, episode payment, episode-of-care payment, case rate, evidence-based case rate, global bundled payment, global payment, package pricing or packaged pricing.|
|Bundled Payments for Care Improvement Initiative||Payment arrangements that include financial and performance accountability for episodes of care.|
These pseudo-scientific phrases seem as though they are legitimate. In actuality, they are linguistic manipulations of the public mind intended to instill belief that the smartest people in the room have only your best interests at heart. Well, they do not.
We’ve previously discussed Evidence-Based Medicine and Electronic Health Records and how medical data is being gobbled up and spit out by Optum, (wholly owned by insurance giant UnitedHealth Group). This is all in concert with Obamacare law, which sets forth the marching orders for the cartel to follow.
Now Get to Know Value-Based Care
We know that Evidence-Based Medicine has not been well established. The concept has not been tested in the way, for example, a new drug is subject to clinical trials. The book, “Debates in Values-Based Practice: Arguments For and Against” published by Cambridge Press last year, reveals an international perspective on how opinions about the legitimacy of Evidence-Based and Value-Based Care vary widely.
Think about the Electronic Health Records requirement of Obamacare. With typically less than 8 minutes for a patient consultation, those in charge of your care are arduously sitting at computer stations or balancing tablets on their laps, typing away madly to make sure that all the mandatory boxes are checked as they conduct their examination of you. They know that dozens of pages of information must be completed in order for doctors and hospitals to receive compensation.
Many doctors and physician assistants interviewed by TAMMM staff tell us they whiz through these forms, often putting blanket NOs for answers which a patient may not be forthcoming (or truthful) in answering or for which they are simply too embarrassed (or outraged) to ask you about. The result in engineering terms: garbage in: garbage out!
Shouldn’t it matter to know just how reliable are these health records? Never mind. Based on the all-knowing electronic records, panels of government and insurance overlords are basing your future treatment on them. This is what their evidence-based practice embodies—using pseudo, unverified data as a basis for decision making about your costs and care.
The nobles take the pseudo evidence and spin out the rules for Value-Based Care. This now serves as the basis for how much insurance companies—or the government—will spend to treat any given patient.
In short, Electronic Health Records serve as the basis for Evidenced-Based Medicine. Evidenced-Based Medicine is used to calculate Value-Based Care models and outcomes. Value-Based Care models then serve as the basis for how much a given case is worth or, put another way, how much money will be assigned to price-fixed Bundled Payments!
Obamacare’s Medical Pseudoscience is Firmly In the Hands of UnitedHealth Group
Of course, this is dense stuff and it’s meant to be! Understanding the double-talk and rationalizations put forth by industry giant UnitedHealth Group and the government is paramount to unraveling this whammy.
Already, Bundled Payment models are being institutionalized: fixed amounts of money made available to treat a patient who falls into or near an established model. If the amount of actual care is less than the model allows, the hospital and doctor get to keep the difference. If the amount of actual care is more, then the doctor and/or the hospital must pick up the difference.
If this sounds rational to you, please remember that since the reliability and veracity of the entire process has been untested and unproven, the decision makers at the government and their insurance cartel partners, in their sole discretion, are determining how much they will spend on any given case. They conjecture what the patient outcome should be, but they do so based on a foundation made of quicksand.
The winners are the insurance cartel. The losers? Patients beholden to models not based in reality and who can no longer afford deductibles or outrageous premiums. And taxpayers who are always left footing the bill. Intentions are always lofty. We’re told care is going to be so much better dispensed and costs will be reduced! Instead, those at the top make more money for delivering less and charging more.
Let’s have a quick look at what others are saying about this ploy.
This 2004 Columbia University study, “The Evidence For and Against Evidence-Based Practice” says the question proponents of evidence-based medicine face is whether there are enough high-quality studies available so that evidence-based decisions can be made.
… the alternative to using evidence-based interventions—with their known rate of failure—is to use unproven procedures, based only on the hope that they may work, but without any real knowledge of how often they do or do not, except our recall of successful cases. However, memory is a slippery thing. We do very well in recalling our successes, but very poorly in remembering our failures—what has been called the ‘‘denominator problem.’’
Evidence-Based practice is simply a cost-cutting tool. The study correctly predicted that especially with the growth of externally managed care in much of the Western world (even in social welfare states) “there is a very real danger that Evidence-Based practice will be used by governments, insurance companies and other payers as a means of imposing the fastest, least expensive form of intervention.”
Fast forward to the Obamacare era. The Electronic-Health Records requirements has led us to this very place and will make certain all hurdles are jumped.
This article that appeared on the Fierce Health Finance blog on June 8, 2015, “Hospitals, healthcare systems inch toward value-based payments,” dispels any doubt that about whether we are transitioning to more value-based care and payment delivery models.
Obama’s fundamental transformation of America includes the sweeping renovation of the way medical money changes hands. An influential group of healthcare providers and payers formed the Health Care Transformation Task Force (HCTTF) in early 2015 to hasten the industry’s transition to value-based models, all with the promise that the practice will “reduce costs and strengthen outcomes.”
This is all tied to Medicare and Medicaid services that are setting the tone for how healthcare is being delivered. Time will tell, if current reports aren’t proving it already, how much impact their efforts will actually have on better health, better care and lower costs.
Who Owns the Value Proposition?
As we’ve exposed, UnitedHealth’s Optum is seizing control of the consolidation of all evidence-based medicine data that there is available. In fact, they believe that Electronic Health Records are insufficient to tell us what we really need to know. They need to know much more, like the socioeconomic status of patients, for starters.
Their cooperation (collusion?) with government entities (HHS, CMS, and apparently the NSA as Forbes indicates could be the case) forms a most perfect union. Optum will decide on the price of a Bundle Payment based on their own convoluted formulas and conjectures. They have seized the domain of Evidence-Based Medicine. The government seems happy with this arrangement.
Optum’s latest Health Advantage Brochure touts the virtues of Value-Based pricing, in essence claiming they have enough information right now to be able to price what a typical medical service should cost. That price is based on the premise that thanks to Electronic Health Records and Evidence-Based Medicine, they have perfected the analyzation of the algorithms in order to determine the price for a treatment, say a case of pancreatitis.
Their interpretations are supposed to be Gospel as they gather your personal info—with the support of Obamacare and HHS—used to set the pricing standards for all. Some may call this racketeering or price fixing. We do!
The Legacy of Andy Slavitt
The man for the job at the Center for Medicare & Medicaid Services (CMS), is Mr. Andy Slavitt, who’s been serving as acting administrator for CMS since 2014. Obama has now nominated Slavitt to permanently take the reins. What’s his background again? Oh, that’s right. He formerly served as group executive vice president at Optum and was CEO of OptumInsight, Optum’s health information technology division. Cozy, right?
A healthcare consulting firm representative says that Slavitt enters the fray at a time when “there are hundreds of rules coming out over the next 18 months, and all of them will require thoughtful consideration and working with Congress.”
Can the public sit back and allow this travesty to continue? Not only does UnitedHealth Group dominate the health insurance industry, they are now, with POTUS’ endorsement, installing their very own man to run the Medicare and Medicaid side of healthcare.
Mr. Slavitt was in charge of creating the technology for UnitedHealth which cranks out the “right” answers concerning patient outcomes and what they consider to be appropriate charges. Now Slavitt is a government man fingered by POTUS to “help” Medicare and Medicaid get it right.
This shameless takeover has stirred the ire of many in Congress. A hot debate and investigation are underway concerning Mr. Slavitt’s potential conflict of interest. At least this is so far a bi-partisan debate. Hopefully our lawmakers will see the obvious absurdity concerning Mr. Slavitt’s likely loyalties.
What Happened to Fee-for-Service Pricing?
Why would a hospital be so quick to discharge a patient who has still not recovered? Because insurance companies want you to receive minimal care to curb costs. We are all aware that hospitals have specialists on staff solely charged to make sure that patients are discharged as rapidly as possible.
With Value-Based Care and Bundled Payments, it’s all justified and tied up with a beautiful bow. No longer is there a need to charge a fee for a specific service. As we’ve pointed out time and again, the new bundled pricing is based on data collected by stressed-out physicians and practitioners under duress from the government. But Optum will gladly sort through the garbage and serve up a bigger revenue stream.
The National Health Expenditure Projections for 2013-2023 reports that 2013 expenditures for Medicare alone were nearly $600 billion and projected to grow steadily at about 6 percent per year. This does not include Medicaid or private insurance. So this is big business. Big enough to be of keen interest to the privateering health insurance cartel.
It’s fairly clear that Optum grabbed ahold of the data to create these pricing models before anyone else because they were in the position to grab it as soon as they saw the loopholes for profit making. The real outcome be dammed. Normally, it would take years to study what health outcomes should be based on real cases. But these “Optumal” magicians can foresee the future—essentially by controlling it.
With perhaps only one or two of their competitors really interested in being the leader on this (they’ll reap the benefits of Optum’s lead anyway) Optum’s position and justification is that the government isn’t prepared to do this, the Joint Commission isn’t prepared to do this “but we can do it because of our size and position in the industry.” No one is arguing.
In fact, the consolidation of insurance companies that we’ve previously reported on, shows exactly why Aetna wanted to acquire Humana. A July 3, 2015 Forbes article, “Aetna’s $37B Humana Deal Expands Role In Medicare’s Value-Based Care Push” states:
“The combined entity will help drive better value and higher-quality healthcare by reducing administrative costs, leveraging best-in-breed practices from the two companies — including Humana’s chronic-care capabilities that measurably improve health outcomes for larger populations — and enabling the company to better compete with more cost effective products,” the companies said.
Currently, just 20 percent of payments from Medicare are paid via alternative payment models like bundled payments, patient-centered medical homes and ACOs, a rapidly emerging care delivery system that rewards doctors and hospitals for working together to improve quality and to rein in costs. In these models, doctors and hospitals take on more risk that they can streamline the care, improve quality and eliminate bureaucratic inefficiencies.
Do you think Mr. Slavitt will be objective in your favor? Or will he be beholden to his former company?
Here’s What We are Left With
Let’s summarize the outcome of these measures with some realities that include, but are not limited to the following:
- In practical terms, payers are denying diagnostic procedures and first-line drugs in order to achieve cost savings.
- Hospital employed doctors (which make up the majority of physicians in the US) are presently compensated by Relative Value Units (RVU’s). This pits doctors against each other who compete for ever declining compensation. This creates a hostile work environment and backbiting. How does a patient benefit? It also drives up costs since hospitals now must be factored into the payment pie.
- Doctors and hospitals will be looking for the lowest cost providers of goods and services. This means that suppliers must lower their prices or produce products which are cheaper and may not perform as well as preferred equipment.
- Many hospitals completely outsource services in an effort to save. The temptation to reward contracts to the lowest cost bidder is tremendous and often irresistible.
- If something goes wrong and someone gets hurt, sick or dies while in hospital care, real legal questions arise as to who is responsible? The hospital or the outsourced resource?
- Doctors are being penalized financially if they fall outside of the norm when ordering medications, diagnostics and other “off-schedule” treatments.
- The claim that these practices “reward doctors and hospitals for working together” is nice rhetoric but the wars being fought on the front lines by doctors and nurses tell a very different story.
- In order to maximize revenue, nurse practitioners and physician assistants are often substituted to replace doctors. Though admirable professions, these caregivers are by far less trained and are used because they are paid a fraction of a fully trained physician (and there is a shortage of doctors because fewer people take up the practice and fed-up doctors are leaving).
- Staffing is cut back and everyone is asked to do more regardless of their position leaving patients suffering from continued reduction in compensation.
- Those driving these models for payment and care are actually practicing medicine without license. While insurance companies typically have several doctors on staff, their signatures are simply rubber stamps for company representatives. The adjusters making decisions to pay for your care (or not) are often adverse to payment of claims, saying that they are not medically necessary. This is a clever way to avoid the real issue of unqualified and unlicensed people practicing without license.
Those of us here at TAMMM believe there should be high-quality healthcare for the entire population. What we are against is the institutionalization of a system where only a few Oligarchs win and the populace loses. We also strenuously object to the blatant interference of the once-sacred relationship between a doctor and patient. We are attempting to find the roots of the changes that are steamrolling our access to timely, superior and affordable healthcare and hope you will join us in exposing and explaining who is behind the transformation of our medical system.
We hope this extensive discussion will shed light on the well-kept secret that the monopolistic insurance industry has concocted for your healthcare.
They’ve subjected us to a great pseudoscience: Hypnotism. Fortunately, some of us are coming out from under their spell. Let’s see what we can do to stop them in their tracks!