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.

You Should Know


Continuous fetal monitoring (CFM) was introduced in the 1950s. It involves the constant monitoring of fetal heartrate and patterns during labor. It quickly became the standard of care.  Attorneys loved it---it gave them a series of very specific targets through which they could second guess the doctors decisions in malpractice suits.
 
This despite in series after series of exactingly designed studies, CFM was never showed to be of benefit.  Never.
 
More information is not necessarily better, but in medicine it is always more risky.
 
Healthmine, a data analytics firm has released a report on chronic disease management of Medicare plan patients.
 
As you might expect, much of it is a marketing vehicle for Healthmine’s services, but one piece of information stuck out.
 
Chronically ill patients are collecting more data than ever with commercially available monitoring devices, and clinicians are doing virtually nothing with it.
 
To which I say, “good.”
 
Non-clinicians don’t understand, more information does not equal healthier patients, just overloaded and stressed doctors, doctors who are fearful that information will be used against them in a malpractice suit.
 
Information vendors don’t want to hear that. They are constantly trying to convince you that, with their wares, your performance will improve.
 
Some data is indeed essential to do well, sometimes that data is generated by the patients themselves.
 
But never take your eyes of the prize. the goal is not to decide for your doctors what will result in lower costs and better care. The goal is to empower and incentivize your doctors toward those goals themselves.
 
Set them up for success and get out of the way.
 
And win.

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