A report card for 32 payers: not making the grade.

نویسنده

Brandi White

چکیده

Brandi White Y ou couldn’t make up stories like these: Shane Avery, MD, is a family physician practicing solo in Scottsburg, Ind. Earlier this year, his practice received a contract from a major health insurer offering a fee schedule based on 120 percent of Medicare rates. “It sounded fair, and we were about to sign,” Avery said, “but then we read further and found out it was based on 2004 Medicare rates.” “We counteroffered with 120 percent of 2007 Medicare, and they told us they couldn’t do that,” Avery said. “It wasn’t a tough decision for me to throw the contract in the trash.” Alan Falkoff, MD, a family physician practicing in Stamford, Conn., was recently contacted by a major health insurer’s disease management program regarding his performance. The health plan had profiled several patients and identified one who was lacking “needed care” – an LDL screening for the previous 12 months and an A1C test for the previous 6 months. “The ridiculous thing is that the patient hasn’t belonged to my practice for years. He has been in a persistent vegetative state in a nursing home for many years following an anoxic brain injury after coding for cardiorespiratory arrest,” Falkoff said. “I don’t even know if this guy is still alive, but apparently his statistics exist in my quality assessment.” Dean Havron, MD, a family physician in Winchester, Va., who has practiced successfully for more than 15 years, found out in March that a major health insurer had awarded him zero gold stars out of a possible four under its physician performance rating program, which uses claims data to assess physicians’ quality and efficiency, a practice many physicians object to because of the unreliability of the data. “Judging medical quality from claims data is like judging a restaurant by looking at its grocery bill,” Havron says. ➤

برای دانلود رایگان متن کامل این مقاله و بیش از 32 میلیون مقاله دیگر ابتدا ثبت نام کنید

ثبت نام

اگر عضو سایت هستید لطفا وارد حساب کاربری خود شوید

منابع مشابه

Optimization Of The Competitive Model Of The Government And Tax Payer Under The Condition Of The Possible Existence Of Error In Auditing The Tax Payers Income Tax Report

متن کامل

Safe chemotherapy and targeted therapy for treating locally advanced NPC in a G6PD-deficient patient: case report and literature review

The article was first report a case of a 32-year-old female with NPC that is G6PD-deficient. The patient completed induction chemotherapy and concomitant chemoradiotherapy successfully. The patient experienced grade 1 neutropenia , grade 1 diarrhea, and grade 2 acne-like skin reactions during the three cycles of induction chemotherapy. Grade 1 neutropenia, grade 1 diarrhea, grade 2 oral mucosi...

متن کامل

Costs of treatment after renal transplantation: is it worth to pay more?

Objectives: The present study aimed to provide an estimation of the current financial burden of renal transplantation therapy for insurance organisations.Methods: An Excel-based model was developed to determine the treatment costs of current clinical practice in renal transplantation therapy (RTT). Inputs were derived from Ministry of Health and insurance organizations` database, hospital and p...

متن کامل

Fuzzy tonnage-average grade model based on extension principle

Due to the nature of the geological and mining activities, different input parameters in the grade estimation and mineral resource evaluation are always tainted with uncertainties. It is possible to investigate the uncertainties related to the measurements and parameters of the variogram model using the fuzzy kriging method instead of the kriging method. The fuzzy kriging theory has already bee...

متن کامل