Kaiser Health News has an interesting article on safety net hospitals’ revenue cycles improving because of Obamacare:
At Seattle’s largest safety-net hospital, the proportion of uninsured patients fell from 12 percent last year to an unprecedented low of 2 percent this spring—a drop expected to boost Harborview Medical Center’s revenue by $20 million this year…
About 80 percent of the system’s new Medicaid patients had previously been seen by the hospital as uninsured patients, she said. Their enrollment in coverage means the hospital is paid more for their care and is able to direct them to outpatient services and preventive care.
She said that UAMS has also seen a drop in ER visits by uninsured patients — from 6,000 visits in first three months of 2013 to about 4,000 visits in first three months of this year, calling the decline “significant.”
Providers have their preferences as to what patients and insurance scenarios they see. Uninsured individuals have always been the least preferred by both the treatment/clinical side and the finance side for a multitude of reasons. Uninsured patients are more likely to present themselves with more complicated cases as they have been trying to avoid costly treatment for as long as possible so managable conditions tend to fester to crisis conditions and since cost is a massive barrier to follow-up care, uninsured patients tend to be more likely to avoid the full regimen of follow-up care. The finance department wants to avoid uninsured patients because they tend to have more complex and expensive interactions and they have the lowest expected value of payment.
Providers have clear account receivable preferences as to what patients they treat.
The ideal patient from an account recievables perspective pays a very high percentage of the billed charge with a high degree of certainty and a short turn around time and minimal haggling. Excluding celebrity rehab centers and $40,000/year per person coverage, there are few payers who meet this provider ideal. Everything else is a trade-off.
Large group, commercial insurers that offer low deductible plans are often the meat and potatoes of a practices’ revenue cycle. Low deductible means the provider is not chasing members for money after the service has been rendered, and commercial providers tend to pay fairly high reimbursement levels. Commercial providers can vary in the speed in turning around a claim from a week or less to several months. They are more likely to fuck around with a provider’s revenue cycle to eat float and manage their cash flow rather than optimize claims payment to minimize provider float. Medicare Advantage members with low deductible plans will also be “prime” members from an accounts receivable perspective.
Individuals with Medicare Fee for Service, especially beneficiaries with Medicare supplemental policies, often serve as the base of a practice. Medicare pays roughly the average cost of a procedure, so the reimbursement rate is fairly low, and the paperwork constraints are fairly high. Traditional fee for service Medicare will pay clean claims quickly. However, Medicare does tend to reject a high proportion of initial claims because there was either a keying issue, or Medicare won’t pay for certain codes. Supplmental policies, especially from major carriers where the providers know how to file clean claims, eliminate the deductible uncertainty and lag time. CHIP patients in most states will also be similar from an AR perspective to Medicare patients — claims pay quickly at a medium level with some hoops to jump through.
People with commercial insurance with high coinsurance but low deductibles are a twist. The provider knows that they’ll see 60% or 70% or 80% of their contracted rate charge fairly quickly from the insurance company. However, the remaining fraction will have some uncertainty attached as to the amount paid and how quickly it is paid. An individual hit with a cancer diagnosis with a 20% co-insurance and a $5,000 annual out of pocket limit will easily run up $25,000 in contracted rate charges in the first round of treatment. They might have 5G lying around, they might not. They’ll be in a similar situation as people with high deductibles who are described below.
People with commercial insurance but very high deductibles will see their contracted rates be fairly high. A provider has a low probability of seeing the entire deductible in a single lump sum within 30 days of service. The more likely scenario is that an HSA or FSA is emptied out to pay a significant chunk of the contracted rate lump sum, and then either a credit card payment is made (good for the provider, bad public policy) or $45/month for the next 5 years is used to pay the lump sum. That “works” as long as the family with a high deductible plan has no future major medical need. And since major medical needs are non-independent, non-random events, this is not a good bet. This calculation disapears when an individual goes over the deductible amount. At that point, the calculation for the marginal dollar from an AR perspective reverts to major commercial medical carrier — high payments quickly made.
The previous two scenarios – commercial insurance with high deductibles or out of pocket maximums driven by co-insurance — are most of the Exchange policies sold. Bronze plans and catastrophic plans are very high deductible plans. Silver without cost-sharing assistance is a medium to high deductible plans. Platinum, Gold and cost-sharing Silvers are closer in behavior to good commercial insurance in the first scenario. Since most people on the Exchange qualify for some subsidies, the probability of people having a full deductible in cash lying around is fairly low. This can explain some of the narrowness of networks as providers may not be willing to take either the lower than commercial but higher than Medicare contracted rates OR they are worried about their ability to get quickly paid in full so they opt out of some networks that are designed to be low premium cost but high out of pocket plans. Small group employer sponsored insurance with high deductibles will also fall into this bucket.
After this, Medicaid will pay quickly but at a low rate. Pre-PPACA, Medicaid paid significantly less than Medicare. Medicaid tends to pay the marginal cost of a service. Post-PPACA, there is a two year bridge fund to pay primary care Medicaid providers Medicare rates, but that is due to expire at the end of this year. I’m flipping a coin as to whether or not it will be extended. As a policy arguement, paying Medicaid PCPs more has signifcantly improved access and care, but it helps poor people and it is part of Obamacare, so I don’t see 218 votes in the House for an extension. Docs and providers will fill out their roster with Medicaid patients, or use Medicaid as a means of building out a practice when they are fresh out of Med School, but a practice that exclusively sees Medicaid patients will be in constant financial stress.
Finally, there are uninsured patients. The AR perspective is to avoid these patients as they are least likely to pay in full or even to Medicare rates in a short time period. There will always be exceptions, but as a class, the uninsured makes the finance people queasy.
As we saw at the start of this post, the uninsured rate, especially in Medicaid expansion states, is rapidly collapsing which will make the medical finance people happier (plus the side effect of improving material well-being and reducing stress and all of that other very good stuff that accrues to the person who is getting needed care at a needed time and place)
Just yesterday I saw people up in arms because hospitals are cutting their budgets for charity care. For some reason they thought this was a bad thing and something horrible the dusky usurper had done.
I’ll bet more people get treated when the providers get paid than when we have to rely on them to dole out scraps.
My dear, sweet old mother is an emergency room psychiatrist. As part of a negotiation with her department head, she gathered insurance numbers on patients she’d seen, going back about three years. Most months pre-Obamacare, 40% of her patients were uninsured. Medicaid counts as insured. Post-Obamacare, that number dropped to somewhere between 10% and 20%. In terms of money her department is making, that is a giant difference.
Oh, I guarantee you, the fact that a medical center’s revenues are increasing will be viewed negatively.
From an AR perspective, the providers most impacted by the advent of more high-deductible plans are the PCPs of the world. As Richard points out, not that many people on the exchange plans have $5,000 sitting around. At the same time, they will see reimbursement for the annual checkup, which they wouldn’t have received in the past.
Hospitals will not be impacted as badly. If a hospital stay runs into the $10,000 range (based upon the negotiated rate with the carrier) they will now see payment of at least a high percentage of the $5,000 that is above the deductible. They may not have seen anything fromt he uninsured patient. And yes, that $10,000 figure is quite low for anything involving an inpatient stay.
I have seen a lot of people complain about having to buy insurance with a high deductible, saying they are putting money out for premiums and the likelihood of their even getting to use the insurance (other than the checkup) is slim. Well, that is what insurance is all about.
I pay quite a bit for home insurance. Fortunately, I have never needed to have it cover anything. In fact, unless there is a major event, most repairs for minor problems would not cover what I have put in. But I know if there is a major event, it will be taken care of.
I, up until recently, rarely got back what I paid in premiums for health insurance. But I was always glad it was there, just in case.
@Frankensteinbeck: Psych/Mental health, and a few other specialities will see a revolution in financial stability due to PPACA reducing the uninsured rate even if the rates are Medicaid rates, providers will get paid with far less chasing.
The AR model above is a very general model — some specialists (plastic surgery for instance) barely think about it, while PCPs or at least their office managers in small practices are acutely aware of the insurance mix of their panels.
@Richard Mayhew: Back when I was an active provider in the MH field, I always found it interesting that one area where the private insurance tended to pay significantly less than Medicare was in the MH field.
For a standard counselign visit, Medicare would pay a SW or PHD $90 while most insurance (particularly those with a carve out company like Magellan) would only pay $55.
@Ronnie Pudding: Can you expand on that thought?
I maybe a liberal, but alas a Capitalist. I think if you provide a quality product/service you should be paid. If you are really good at something you ought to get rich.
That a hospital offers pro bono work or charity, well good for them. Kudos. But they should get paid. That more people have health care plans and they are getting paid, well that is a very, very good thing.
Iowa Old Lady
Online friend of mine is on the military health insurance and has been scrambling to arrange surgery for his daughter, who’s about to turn 21. Apparently, with that insurance, 21 rather than 26 is the age limit for staying on your parents’ insurance. That needs to change.
@Iowa Old Lady: I can’t help, your question is above my pay grade by a few levels. But I am very curious what the response is. I am a military brat. Also somebody that is a Civil Service kid. Almost everybody in my family is on a government health care plan of some kind. I’ve heard little talk, if any, about how they work with the ACA.
Para 2 (not counting block quote), sentence 3, “regiment” should be “regimen”.
It was a tongue in cheek comment, probably more applicable to insurance companies than hospitals. I think it’s good that Harborview Medical Center is making and not losing money off of this. it keeps them on the right side of the issue.
I had this argument on Daily Kos a couple of months ago. The diarist considered it to be a failure of Obamacare that hospital revenue was increasing. I asked the diarist where they thought the money would go if people started seeing doctors more. (Before anyone starts bashing Daily Kos, I received a number of recs and a positive comment. The diarist also tried to make it out that the ACA was increasing costs without mentioning all of the ways that it also was generating revenue. I think I was dealing with a Single Payer or bust person.)
I’m a regulated capitalist. I don’t think the government should be in the job of planning most things in an economy, but there are things that capitalism by itself will never handle properly.
It is a depressing reflection of the state of discourse in our country right now that the headline initially made me wonder why health-care providers would have an AR preference, given that pretty much all .223 semi-automatic rifles make pretty much the same holes.
That is a very interesting take – and quite in opposition to several commenters at this blog who saw those cut backs as a heartless money grab by organizations who could not wait to stop providing charity care.
half full/half empty?
@Belafon: I just don’t know how anybody that works for a living doesn’t like people are getting paid for quality services rendered. If more people are insured the revenues of a hospital will increase. I mean that is market dynamics 101. Those that could not pay, can pay. If you are taking a $10,000 hit to offer pro bono or charity work and that person instead pays you $10,000, well it ain’t hard math to get a $20,000 change in income.
once again, thank you for this post. you are giving us better coverage than we get pretty much anywhere else.
@Tom Scudder: TY
I think the context for perhaps viewing the increase in hospital revenues as a bad thing (a view I don’t necessarily share) is the concern that this will simply reinforce the pricing of healthcare, which may be seriously out of whack. I’m thinking of Steven Brill’s Time article a while back in which he wrote at length about the opaque system hospitals employ to decide what to bill patients/insurance and the perhaps inflated prices they charge for things.
The problem is that the money isn’t guaranteed to go to the people who are rendering services. Increase in revenue to hospitals can be distributed in a lot of ways. It could go to pay increases to doctors. It could go to pay for more and better nurses. It could pay for a lot of other technical staff. It could pay for technology improvements.
It could also go into the pockets of hospital administrators. Which is where a lot of folks assume it will go, given the object lessons on where increased revenues go in the 21st century. I’m hopeful that, as a class, doctors and nurses will be better organized to make sure that they get their cut and it isn’t all going to the administration, but frankly any extra dollar that a CEO who is already making more than $250K/year gets is a dollar that is wasted.
GHayduke (formerly lojasmo)
In part because it never would have taken place. I remember when I was in nursing school, and marginally insured, I couldn’t even afford the copay, so I was only seen if I was seriously ill.
Word. I learn more about the ACA from RM’s posts than I do from the rest of the internet combined PLUS my real life job (in health care, an as RN).
Not necessarily. Part of what’s happening today is that hospitals wind up overcharging patients who do have insurance to cover the uncompensated care they give to patients who don’t have insurance. If more of their patients have insurance, they should have fewer patients who need uncompensated care, letting them reduce overcharges to cover it. That should create a virtuous circle where prices come down, insurance becomes more affordable, more people get insurance, etc.
This is a big reason worries about Obamacare increasing patient load were overblown. People who didn’t have insurance weren’t actually staying out of the medical system before; they were just using it really inefficiently and creating problems for the people who did have insurance. Getting more people insurance should help with those inefficiencies and wind up making care less expensive.
@japa21: I don’t recall ever having a concern that if I was going to the trouble of buying car insurance that I should at least be getting into some cool major accidents so that it would be worth my while.
A friend of mine undergoing cancer treatment right now posted on Facebook that she had received a letter from her provider saying that she had reached her out of pocket limit (is it that $6350?) and would be required to pay nothing more. She still has another round of chemo followed by radiation, so she called just to be sure: “You mean I can continue my treatments but not pay anything else?” That’s right, they assured her. She was stunned but very happy. :)
It’s easy to understand the confusion given the way people are used to being treated by their insurance companies. When you hear about caps and limits, it’s natural to assume they’re designed to work against you, not for you.
To me, this says again that we really, really need unified billing codes that ALL providers use for submitting claims. G works in healthcare (home infusion pharmacy) and one of the biggest problems they have is that every insurance company (including Medicare) has their own unique set of billing codes for the same goddamn thing, so you have to have someone who knows that HealthNet’s billing code for this antibiotic is XYZ but Cigna’s billing code for the same thing is ABC. It’s incredibly stupid and leads to a lot of errors. Why not say, Everyone uses Medicare’s billing codes, and leave it at that?
Argh! Can I please be released from moderation for mentioning the type of company that sells legal drugs?
@japa21: The other thing people don’t realize is that even with a high-deductible plan, they are likely to pay less for whatever service they need (or at least that was true for me for a long time with my MN individual plan).
I needed a CT scan stat a few years back. It was billed at $4,000 (which is absurd) but then the “provider discount” kicked in and it was around $800. Even then, there was some sort of provider portion paid before I hit my deductible and the net I paid was something like $650 or $700.
Later research indicated that if I had had time to shop around (not likely when you are feverish and, it turns out, have pancreatitis), one can get a cash CT or MRI for under a grand.
But had I been uninsured, I’d have been hounded by bill collectors for the $4K – until either I knuckled under or they “forgave” perhaps 75% or so.
I hope that as hospitals (in expanded Medicare states, at least) can start to adjust their fictional billing rates for non-insured patients to more closely resemble reality and negotiated pricing.
Until then, having a high-deductible plan still should give patients access to the negotiated price, which can be a serious savings.
GHayduke (formerly lojasmo)
LOL. When I asked my intake councillor how much my treatment would cost, he said “how much is your annual out of pocket?”
If we didn’t have two insurance policies, that would have been dead on true. As it is, my wife’s insurance picked up all my OOP costs, and I STILL won’t have to pay anything for the rest of the year, according to my primary insurer.
This is actually required in the ACA, but enforcement has been lagging since there have been higher priority things to fix. There was a big article about it in Time, I think it was, recently.
Yeah, very true.
Just as a personalized example (copied from my comment at K Drum’s blog) of the absurd retail rates, my left pinky tip recently (2014/03) suffered from an extensor tendon detachment. (mallet finger). Made an appointment, filled out/signed 11 pages of forms, quick x-ray, doctor cut a little metal splint and taped it up, told me to not let my finger bend for 6 weeks. Total time including forms, 1 hour. (30 minutes for x-ray and doctor).
Retail rate (I paid a much lower negotiated rate):
Office visit: $250
Splint $2340 (a few codes here, all that really happened was a splint.)
Having walked the mine field of mental health providers with solid, reputable, employer provided insurance I am not sure if this is a specialty that will yield to much improvement.
The problem was always reimbursement rates. I could never find doctors willing to accept new patients at the insured rates. If I wanted to pay myself at whatever rate they chose to charge I could be seen immediately, if I wanted to use insurance it would be at least 6 months, more probably never. I know the doctors didn’t care and I am pretty sure the insurance companies were OK with it as they paid out even less.
This held true across many difference insurers and different plans.
Are safety net hospitals seeing any similar improvement in non-Medicaid expansion states? Because the last thing I heard was that they were in trouble.
@Bill Arnold: If you’re interested in what different providers charge for the same services, check out https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/index.html
You discover that a “Level I Debridement & Destruction” costs $343 at St Louise in San Jose/Gilroy CA and $24.60 at UC Irvine Med Center. Fascinating stuff, also including what they actually get paid as opposed to what they bill.
@Mnemosyne: because private industry, proprietary standards, yada yada yada…. there are codes that are used in the industry to help identify diagnosis and results (ICD9 or 10) depending upon your flavor, codes that are used to describe results and procedures (LOINC) but not everyone is interfaced yet nor do all of your vendors play nice with each other, your hospital information system versus your lab versus your doc’s EHR versus the Billing versus a 3rd party vendor for special services vs radiology yada yada yada. The scary thing is, some vendors have multiple hats in various rings and sometimes even their own products don’t work well together. There is a LOT about healthcare that isn’t standardized but no one ever sees it (thankfully) but everyone is more or less working to the same end, efficient, accurate health care diagnostic tools that bring about better patient outcomes (damn that sounded way too much like a mission statement).
@mdblanche: That question varies —
If the state has a high level of Exchange policy sales and a fairly high level of legacy Medicaid participation, the safety net hospitals are losing DSH payments (what the Feds kick in to cover concentrated uninsured/uncompensated care) but are getting a bit more on the insured side. A priori, someplace like New Hampshire might be OK
On the other hand, safety net hospitals in say Oklahoma or Alabama where there was a low level of eligible legacy MA participation, high demand for Medicaid expansion and active resistance to Exchange implementation, the loss of DSH payments without corresponding increase in insured payments will kick the everliving shit out of safety net hospitals.
Are we talking about the same major vendor that starts with an O and is a made up feel good word that almost is close enough phonetically to make one have a sunny view on the future?
Yeah, that vendor is a fucking blast to work with when we try to make their data sets play nicely with our data sets and then their data sets again.
We can do A to Mayhew and B to Mayhew but getting A to Mayhew to B is guaranteed employment for quite a few people for quite a few years.
@Richard Mayhew: well I was attempting to speak generically, I know that there multiple viewpoints in play from the position of hospitals as standalone or corporate entities. Some prefer what they call a “best of brand” solution, pick the best vendors in their various fields of expertise (again, who is classified as the best is a subject of vigorous debate) say Lab, HIS or Radiology, Anatomic Pathology what have you…. and there are others that feel that if we buy all the products from one vendor who offers a “total suite of products” is the way to go. Both camps have a certain validity to them but from my position in the industry (as a hired medical information techie gun for hire) standardization is a goal that everyone would like to achieve but humanity being what is it, damned difficult to achieve without a monopoly. Even those folks that offer a complete suite of packages for the various departments within a hospital have exhibited tendencies that their left hand is completely unaware of what the right is doing or what the brain has planned.
To me, this is an argument for NHS. Get rid of the distinction between insurer and provider and you get rid of the need to code all this stuff for payment. It’s a whole layer of bureaucracy eliminated.
I’m pretty sure the NHS still has to code diagnoses, if only for statistical purposes, and even Universal Medicare would want to know how much is being spent on X diagnosis versus Y diagnosis. So coding will never go away.
@Iowa Old Lady:
Tricare (military) coverage for dependents was not included in the ACA for extending coverage to children up to age 26. Children age off at 21, unless fully disabled before they would otherwise lose coverage. However, there are options. If the child is enrolled full time for higher education it extends coverage to age 23, but there is some paperwork that needs done. There is also the Tricare Young Adult program until age 26. Adult children who would otherwise age off can buy into this program for either $156 to $180 per month (there are two types of coverage). It may be more expensive than ACA subsidized plans, but Tricare is IMO excellent coverage. The highest annual deductible is $300/family, and the highest annual catastrophic cap is $3000. Plus everything seems to count towards that cap – the deductible, cost shares, even pharmacy copays. We have had only two problems with getting prior authorizations, and both were quickly resolved by phone.
As a parent to a 19 yr old, and a 21 yr old, I hope your friend is able to have their child covered – but paperwork always takes time. For anyone whose kids are nearing this age remember to check way ahead of time with both your medical and dental insurers to see what you need to do.
@angh: mind if I front page this?
@piratedan: Agreed — standardization would be wonderful and if the integrated service providers actually offered fully integrated solutions that played nicely with each other, that would be wonderful.
If Harborview’s rate of self-pay (no-pay) patients is going down, then the for-profit hospitals must be seeing much better patient revenue. Harborview Medical Center does not turn patients away if they cannot pay, so many HMC patients have already tried to get care at other hospitals. And, as the five-state trauma center, some of the patients who are flown in from other states hit the bottom line pretty hard.
Judy in SD
Totally off topic but a question for Richard. On May 7th you asked for volunteers to participate in an online survey/research study. The post was titled “Cause It’s Science.” I am curious if you will have a follow up post at some point in time which will give us more information about the study and/or some of the results?
@Richard Mayhew: well it’s not like there aren’t players attempting to make this happen in healthcare IT, there are because for the most part, the people in the industry, generally speaking, want to provide good health care and yet we have multiple threads being pulled at the same time…. the finance people want to get paid, the docs and nurses want to practice medicine, the academics want data to research to know what works and what doesn’t and tech staff just want to help without being yelled at. The patients, just want to get well, thank you very much.
The devil is in the details, squeaky wheels get greased and personalities get in the way. healthcare is just like any other business and yet unique unto itself in that you usually aren’t too concerned about what store made your e-book reader but you do give a crap about how and who is treating your kid in the hospital but there are still internecine departmental squabbles and people holding grudges and being petty tyrants.
Feel free to page it, and here’s some links.
I am just a Tricare beneficiary, not an expert. See the Tricare website at http://www.tricare.mil/ for details – for Tricare Young Adult check http://www.tricare.mil/TYA for more info. Their phone operators are great also, once you get past the automated system. They have answered many questions for me in the past.