As Commercial Capitation Sinks, Can California’s Physician Organizations Stay Afloat?

http://www.chcf.org/publications/2016/11/commercial-capitation-sinks

Image result for Boat Staying Afloat

California is seeing the decline of capitation — fixed prepayment for care of a defined population — particularly for commercial health insurance products. This issue brief explores the impact of this trend on the state’s medical groups and independent practice associations (IPAs). The main question at hand is whether California’s delegated model will remain sustainable with lower levels of commercial capitation.

The analysis is based on both quantitative and qualitative data. The medical group and IPA leaders interviewed for this research made a number of observations, including:

  • The near future is uncertain. Declining capitation has not yet had a big impact on their operations, but they suspect it may soon.
  • Change thus far has been slow enough that organizations have been able to adapt.
  • Declining prepayment will not impact clinical decisionmaking.
  • Medicare and Medi-Cal offer more opportunities to accept capitation, but these do not necessarily compensate for the loss of commercial capitation.
  • Leaders are concerned that high deductibles may adversely affect the health of patients.

The research points to the importance of continuing to track changes in the payment environment of California’s capitated, delegated physician organizations. Although the decline in commercial capitation has been slow enough that it has not yet led to significant changes in operations, it may soon do so.

The full issue brief is available as a Document Download.

Click to access PDF%20CommercialCapitationSinks.pdf

 

When It Comes to Seeing a Doctor in California, the Uninsured Still Fare Worst

http://www.chcf.org/articles/2017/01/when-seeing-doctor

California Physicians Accepting New Patients by Payer, 2015

With repeal of the Affordable Care Act (ACA) on the horizon, and no replacement plan in sight, millions of Californians are at risk of losing their coverage. Approximately 5 million Californians are currently covered under the ACA. The state’s uninsured rate, which hit a historic low under the ACA, could start to rise again depending on what happens in Washington in the coming weeks and months.

It’s worth remembering the multiple barriers that people without insurance face in our health care system. I am reminded of some key findings from a 2015 survey of California physicians that the University of California, San Francisco, released last fall with support from the California Health Care Foundation.

The survey asked, among other questions, if physicians were accepting new patients who had various types of insurance (private, Medicare, or Medi-Cal) or who were uninsured. The survey also asked physicians if any of their existing patients were uninsured.

As the slides below show, the uninsured face the hardest time getting accepted into a physician’s practice. Only 38% of all California physicians said they accepted new uninsured patients in 2015; only 55% said they had any uninsured patients. The sample of physicians includes emergency department (ED) doctors who are legally required to see all persons who come to an ED, regardless of whether they have insurance.

Top 10 challenges facing physicians in 2017

http://medicaleconomics.modernmedicine.com/medical-economics/news/top-10-challenges-2017

2016 was a challenging year on many fronts for healthcare providers.

Physicians have just started to digest the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and its changes to physician reimbursement. A long presidential election finally reached its conclusion, but the consequences of a Republican Congress and President-elect Donald J. Trump for U.S. doctors and patients remain unclear. And running a private practice did not get any easier. Balancing the need to deal with patients who won’t listen or won’t pay while also seeking positive patient satisfaction scores remains a daily struggle for many. 

These were just some of the challenges physician readers told Medical Economics they experienced this year and anticipate continuing for the foreseeable future. 

For the fourth consecutive year, Medical Economics reveals its list of obstacles physicians will face in the coming year and, more importantly, how to overcome them. For this latest presentation, we asked readers to tell us what challenges they face each day and where they needed solutions.

Here are their responses, starting with the biggest challenge of the coming year.

How doctors can overcome payment obstacles in 2017

http://medicaleconomics.modernmedicine.com/medical-economics/news/how-doctors-can-overcome-payment-obstacles-2017?utm_source=TrendMD&utm_medium=cpc&utm_campaign=Medical_Economics_TrendMD_0

 

Metro Phoenix doctor indicted in $100 million Tricare fraud case

http://www.azcentral.com/story/money/business/health/2017/01/01/metro-phoenix-doctor-indicted-in-100-million-tricare-fraud/95969880/?utm_source=RealClearHealth+Morning+Scan&utm_campaign=be01ccd91c-EMAIL_CAMPAIGN_2017_01_03&utm_medium=email&utm_term=0_b4baf6b587-be01ccd91c-84752421

Health care fraud indictment

A Valley physician is among a dozen doctors, pharmacy owners and marketing pros accused of a kickback scheme that prosecutors allege involved a sham medical study used to bilk up to $102 million from the publicly-funded federal health program for military family members.

Walter Neil Simmons, 47, of Gilbert, an emergency medicine doctor who has worked at two metro Phoenix hospital chains, was indicted in October in U.S. District Court in Dallas on one count of conspiracy to commit health-care fraud. The federal charge carries a maximum sentence of 10 years in federal prison and a $250,000 fine.

Editor’s Corner: A fraud scheme in a league of its own

http://www.fiercehealthcare.com/antifraud/editor-s-corner-a-fraud-scheme-a-league-its-own?utm_medium=nl&utm_source=internal&mkt_tok=eyJpIjoiT1RWa01EQmxZV1l6WkdGbSIsInQiOiJnVitHTEdcL0c4M1JSOENxdGk2V0Q5U0ZQc3V6TFFDdEg4Y1VUWllWbVE3aVNwU2Y3QUpZdmE5aEE3ZEVRWGMyVk14V0YyUHR5MEZvMDByck9wVmFqXC9ib3pRZnNyb0lmM05sZXl1eVZJRjhBPSJ9

opioid

Earlier this month, authorities arrested Christopher Bathum, the self-described “rehab mogul” and founder of more than two dozen sober homes and outpatient drug treatment facilities in California and Colorado. Bathum was charged with fraudulently billing four different insurance companies more than $176 million.

According to a release by California Insurance Commissioner Dave Jones, Bathum, the CEO of Community Recovery of Los Angeles (CRLA), and Kirsten Wallace, the company’s CFO, lured drug addicts to CRLA facilities, stole patient information in order to purchase health insurance policies without their consent, and then billed insurers for drug treatment services beyond what was provided.

Anthem Blue Cross Blue Shield, Cigna, Health Net and Humana paid the company $44 million before discovering the scheme. Bathum profited handsomely.

But the 50-count fraud complaint (PDF) against Bathum paled in comparison to the allegations contained in a separate lawsuit filed by the Los Angeles County District Attorney’s Office. In that suit, Bathum was charged with sexually assaulting and raping female patients between 2013 and 2016, even going as far as to coerce recovering addicts with drugs.

The allegations against Bathum—who has pleaded not guilty to all charges—are a culmination of nearly a year’s worth of negative press for the rehab mogul. In December, LA Weekly wrote a lengthy feature on Bathum that included allegations from one former patient claiming Bathum sexually assaulted her. At that point, Bathum was also being investigated by city and state law enforcement agencies, along with “nearly every large insurance company in California,” according to LA Weekly.

Three more women have come forward since then, filing civil lawsuits accusing Bathum of sexual assault. In June, Bathum was the target of an hourlong 20/20 investigation that focused primarily on his relationship with several female patients. One woman described how Bathum sexually assaulted her in a cramped sweat lodge at a Malibu sober home. Another said Bathum took her to a seedy Malibu hotel where he overdosed on meth and heroin.

In both the LA Weekly story and the 20/20 special, Bathum repeatedly and categorically denied all of the allegations against him, including any insinuation that he had sexually assaulted female patients or used drugs. He blamed identity theft for the ambulance records linking him to an overdose. At one point he filed a libel lawsuit against LA Weekly’s parent company, which he later withdrew.