Medicare + (No) Choice
Your article on Medicare+Choice PPOs "Medicare + more choice" (Nov. 11, p. 40) prompted me to write to describe a chronic problem that many hospitals encounter under Medicare+Choice, especially facilities with per diem inpatient rates.
Managed-care organizations use resources such as Milliman & Robertson's Optimal Recovery Guidelines to decide whether they will pay for hospital care. Because these guidelines are very insensitive to patients with multiple medical conditions and complex discharge planning needs-situations frequently encountered in the elderly-Medicare+Choice health plans frequently deny payment for inpatient care that the patients' physicians order and hospitals provide in good faith and with reasonable clinical and humanitarian justification. Health plans' expectations that complex services such as intravenous therapy can be devolved to the home setting are simply not realistic for most elderly patients.
Often, Medicare+Choice plans engage in an orgy of unbundling as a way of addressing patients with multiple problems, with an eye toward justifying denial of payment. In 2000, the entire admission to my hospital of a 73-year-old patient with a dominant hemisphere stroke, a fever of 103.5 degrees, severe anemia and blood in her stool initially was denied by her Medicare+Choice plan because "the patient could receive outpatient antibiotics, the colonoscopy could be done as an outpatient and the patient could receive outpatient rehabilitation."
When hospitals negotiate per diem inpatient rates with Medicare+Choice health plans, they often base their starting payment targets on the average Medicare DRG reimbursement divided by the "expected" length of stay. Whatever rate finally is negotiated, by denying payment for as many as 20% of the days, the health plans give themselves a hefty discount and force hospitals to operate at a loss.
Hospitals should be supported in their efforts to negotiate contracts with managed-care plans that specify a more fitting utilization framework or even a different payment system such as case rates, with adjustments for outliers and problem dispositions. Perhaps we should also try to change federal rules to specify that Medicare+Choice plans must use utilization criteria that are proven to be appropriate for Medicare patients (which remain to be developed) or even to require payment for any care ordered by a physician. Otherwise, Medicare+Choice ought to be resisted by the hospital industry.
Lawrence Faltz, M.D.
Phelps Memorial Hospital Center
Sleepy Hollow, N.Y.
No avoiding conflicts
I read with some interest the article concerning the ethics of serving on for-profit boards while also serving in key positions in the not-for-profit sector "Boardroom disclosure" (Dec. 2, p. 8).
Having been on both sides of the issue in the past, I must agree with (past American Hospital Association Chairman) Larry Mathis. I also don't see how you can avoid the conflict, and even the appearance is a problem.
Martin Smith Jr.
President and chief executive officer
Global Medical Management
One from column A
From which trite talking-points paper did your editorial "Tenet's turn" (Nov. 18, p. 28) come? It sounds like a fill-in-the-blanks political ad:
"___________ isn't just any other business, and the need to satisfy investors with earnings growth each quarter drives some executives to do things they might not do otherwise."
Select your favorite story line:
1. Airlines: safety vs. profits? Where malpractice is almost always fatal.
2. Pharmaceuticals: research vs. profits? If decisions were made on the basis of social need and without regard to profit, they would have invented and distributed polio vaccine, antidepressants and many painkillers even sooner, right?
3. Banks: Your money is safer with the government or a not-for-profit group (think savings and loans), and don't forget to bid on that ocean-front lot in Arizona.
And since when are nonpublic and not-for-profit organizations lily-white? How many HHS' inspector general's office claims have been made against these organizations, and how many fessed up?
Look a little deeper for a story. This one, like most, is about people not their organizations' tax status.
Robert Thornton Jr.
Chief executive officer
SunLink Health Systems