Category Archives: Payor Contracting

Payer mix in the nation’s top 19 hospitals

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Becker’s calculated the payer mix within the nation’s top ranked hospitals to determine the share of their patients covered under commercial plans, Medicare, Medicaid, Medicare Advantage, uninsured/bad debt and charity care.

The 2019 data released April 5 is from the coverage, cost and value team at the National Academy for State Health Policy in collaboration with Houston-based Rice University’s Baker Institute for Public Policy.

Payer mix in the nation’s top 19 hospitals:

(1) Mayo Clinic Hospital — Rochester, Minn.

Commercial: 50 percent 

Medicare: 33 percent 

Medicare Advantage: 9 percent 

Medicaid: 7 percent

Charity care: 1 percent 

Uninsured / Bad debt: 0 percent 

(2) Cleveland Clinic Hospital

Commercial: 45 percent 

Medicare: 24 percent 

Medicare Advantage: 17 percent 

Medicaid: 12 percent 

Charity care: 1 percent 

Uninsured / Bad debt: 1 percent 

(3) Ronald Reagan UC Los Angeles Medical Center

Commercial: 45 percent 

Medicare: 27 percent 

Medicaid: 18 percent 

Medicare Advantage: 8 percent 

Charity care: 0 percent 

Uninsured / Bad debt: 0 percent 

(4) Johns Hopkins Hospital — Baltimore

Commercial: 46 percent 

Medicare: 28 percent 

Medicaid: 22

Medicare Advantage: 2 percent

Uninsured / Bad debt: 2 percent 

Charity Care: 1 percent 

(5) Massachusetts General Hospital — Boston

Commercial: 48 percent 

Medicare: 32 percent 

Medicaid: 11 percent 

Medicare Advantage: 7 percent

Charity care: 1 percent 

Uninsured / Bad debt: 1 percent 

(6) Cedars-Sinai Medical Center — Los Angeles

Commercial: 42 percent 

Medicare: 41 percent 

Medicaid: 10 percent

Medicare Advantage: 6 percent

Charity care: 1 percent 

Uninsured / Bad debt: 0 percent 

(7) NewYork-Presbyterian Hospital — New York City

Commercial: 34 percent

Medicaid: 25 percent 

Medicare: 22 percent 

Medicare Advantage: 17 percent 

Charity Care: 1 percent 

Uninsured / Bad debt: 1 percent 

(8) NYU Langone Hospital — New York City

Commercial: 42 percent 

Medicare: 25 percent 

Medicaid: 19 percent 

Medicare Advantage: 6 percent 

Charity care: 1 percent 

Uninsured / Bad debt: 0 percent 

(9) UC San Francisco Medical Center 

Commercial: 42 percent

Medicaid: 25 percent 

Medicare: 25 percent 

Medicare Advantage: 5 percent 

Charity Care: 1 percent  

Uninsured / Bad debt: 0 percent

(10) Northwestern Memorial Hospital — Chicago

Commercial: 52 percent  

Medicare: 27 percent 

Medicaid: 11 percent 

Medicare Advantage: 7 percent 

Charity care: 2 percent

Uninsured / Bad debt: 1 percent

(11) Michigan Medicine — Ann Arbor

Commercial: 53 percent 

Medicare: 20 percent 

Medicaid: 14 percent 

Medicare Advantage: 11 percent 

Charity care: 1 percent 

Uninsured / Bad debt: 1 percent 

(12) Stanford Hospital — Palo Alto, Calif.

Commercial: 46 percent 

Medicare: 34 percent 

Medicaid: 13 percent 

Medicare Advantage: 7 percent 

Charity care: 0  

Uninsured / Bad debt: 0 

(13) Penn Presbyterian Medical Center — Philadelphia

Commercial: 46 percent

Medicare: 29 percent 

Medicaid: 13 percent 

Medicare Advantage: 12 percent 

Uninsured / Bad debt: 1 percent 

Charity Care: 0 

(14) Brigham and Women’s Hospital — Boston

Commercial: 53 percent 

Medicare: 30 percent

Medicaid: 10 percent

Medicare Advantage: 6 percent 

Charity Care: 1 percent 

Uninsured / Bad debt: 1 percent

(15) Mayo Clinic Hospital — Phoenix

Commercial: 51 percent

Medicare: 42 percent 

Medicare Advantage: 4 percent 

Medicaid: 3 percent 

Charity Care: 1 percent 

Uninsured / Bad debt: 0 percent 

(16) Houston Methodist Hospital

Commercial: 43 percent 

Medicare: 33 percent 

Medicare Advantage: 18 percent 

Charity care:3 percent 

Medicaid: 2 percent 

Uninsured / Bad debt: 1 percent

(17 — tie) Barnes-Jewish Hospital — St. Louis

Commercial: 43 percent 

Medicare: 29 percent

Medicare Advantage: 13 percent

Medicaid: 10 percent

Charity care: 4 percent 

Uninsured / Bad debt: 1 percent 

(17 — tie) Mount Sinai Hospital — New York City

Commercial: 33 percent 

Medicaid: 28 percent 

Medicare: 22 percent 

Medicare Advantage: 15 percent 

Charity care: 1 percent

Uninsured / Bad debt: 0 percent 

(18) Rush University Medical Center — Chicago

Commercial: 41 percent 

Medicare: 31 percent  

Medicaid: 20 percent 

Medicare Advantage: 6 percent 

Charity care: 2 percent

Uninsured / Bad debt: 1 percent

(19) Vanderbilt University Medical Center — Nashville, Tenn.

Commercial: 47 percent  

Medicare: 20 percent 

Medicaid: 18 percent 

Medicare Advantage: 10 percent

Charity care: 4 percent

Uninsured / Bad debt: 1 percent 

Why insurers, health systems are breaking up

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Insurers and health systems across the U.S. have been at odds during the most recent cycle of contract negotiations, and terminated contracts are affecting thousands of patients.

As hospitals continue to recover financially from the COVID-19 pandemic and deal with higher supply costs and employee wages, many organizations have tightening margins and hope to negotiate higher rates with insurers as a result. Hospitals are also pointing to rising inflation as a reason for needing higher rates.

One recent example is Fort Lauderdale, Fla.-based Broward Health’s public breakup with UnitedHealthcare. Thousands of the insurer’s beneficiaries went out of network with Broward April 1 after the two sides failed to agree on a new contract. Broward reportedly asked UnitedHealthcare for a pay increase to the same level UnitedHealthcare pays other South Florida health systems.

UnitedHealthcare said Broward’s rate increase request would amount to 88 percent higher reimbursement for its providers in the next four years, which the insurer said was “unreasonable.” Negotiations continue, but patients are out of network in the meantime.

Blue Cross & Blue Shield of Mississippi and the University of Mississippi Medical Center let their contract expire April 1 after they failed to agree on pay rate increases, according to the Clarion Ledger. The medical center treated more than 50,000 patients in the 18 months before the contract expiration.

LouAnn Woodward, MD, vice chancellor for health affairs and dean of the medical center’s school of medicine, said the health system wants “fair reimbursement” from Blue Cross & Blue Shield to reinvest in its facilities and programs. The insurer said the medical center wanted a 30 percent overall rate increase, including a 50 percent increase for some services, according to the newspaper report.

Physician groups and surgery centers aren’t immune from insurer conflicts. Blue Cross Blue Shield of Illinois terminated its contract with Springfield (Ill.) Clinic late last year, knocking 100,000 beneficiaries out of network.

Payer contracts, physician pay still anchored in fee-for-service

Posted on by • Posted in Fee for Service Reimbursement, Healthcare Reform, Payment Models, Payor Contracting, Performance Metrics, Performance-Based Incentives, Physician, Physician Compensation, Quality Incentives, Quality Measures, Quality Reporting, Risk-Based Compensation, Value Chain, Value Creation, Value-Based Contracting, Value-Based Healthcare • Leave a comment
https://us17.campaign-archive.com/?e=d1e747d2d8&u=526c5e99ee0439b6f83f7c051&id=5b1b015fbd

The healthcare industry has made some strides in the “journey to value” across the last decade, but in reality, most health systems and physician groups are still very much entrenched in fee-for-service incentives.

While many health plans report that significant portions of their contract dollars are tied to cost and quality performance, what plans refer to as “value” isn’t necessarily “risk-based.” 

The left-hand side of the graphic below shows that, although a majority of payer contracts now include some link to quality or cost, over two-thirds of those lack any real downside risk for providers. 

Data on the right show a similar parallel in physician compensation. While the majority of physician groups have some quality incentives in their compensation models, less than a tenth of individual physician compensation is actually tied to quality performance. 

Though myriad stakeholders, from the federal government to individual health systems and physician groups, have collectively invested billions of dollars in migrating to value-based payment over the last decade, we are still far from seeing true, performance-based incentives translate into transformation up and down the healthcare value chain.