From Dr. Tom's Desk
Kickbacks will absolutely kill your performance.
A Federal judge refused to dismiss a False Claims Act prosecution of Humana and Roche in which a whistleblower alleged that payments were made to allow certain diabetic products to be placed on the formulary of certain of Humana’s Medicare Advantage plans.
As Medicare Advantage gets bigger you’re going to see more and more of this. And as CMS allows for more “carve-ins” like home care and hospice, expect the problem to get even bigger.
Here’s a report from the field:
“In my career, there were cases where I was forced to refer to a number of “exclusive” providers who presence on the referral list made no sense. They provided terrible service, inadequate follow-up and horrible products---yet they we always had to refer to them year after year. Pharmaceuticals were even worse, every year I had to change my patients back and forth between drugs in the same class for no apparent reason.”
“I suspect all this was due to kickbacks and payoffs high up the insurer’s food chain”.
“Sometimes it was so bad, we as an organization had to opt out. We had to start supplying our own durable medical equipment, our own transportation.”
“And even though each time it started off expensive with a big learning curve, we always, ALWAYS, ended up better off than if we had stayed with the status quo.”
“I did the same thing with my patient’s meds. I tried to always use generics. When I couldn’t I warned them about the potential for formulary changes and the need to start exploring other options for keeping a supply of steady supply of the chosen meds even if the formulary status changed.”
“Every once in a while, the situation got so bad, we complained---complete with spreadsheets showing how much the product or service in question was costing us and them.”
“And sometimes, we were even able to get a change, once even in the middle of a contract year.”
These kickback arrangements are going to happen. And because they’re not based on the value the product can bring to the patient, they are going to harm your performance.
Stay ahead of them. Internalize the services you can. Execute care strategies to minimize their impact.
And when they hit you really hard---complain, complain, complain.
The fact that insurer, rather than the government, is now on the hook for care costs will work in your favor.
Us that fact whenever you can.