Network contracting. Congress may drop a bomb on Pathology

[AZpath]

The out of network bill that came out of the House this week is distinctly unfavorable to hospital based providers.
It gives the payors all the power to set fees without negotiation.

Under this bill, they will likely be able to cut rates like Anthem is doing. There would be not recourse for providers.

The White House's statement this week is also very unfavorable to providers. They favor bundling all hospital payments for all hospital services.
You would have negotiate with the hospital for private insurance payment.

If either one of these go through it would be highly disruptive.
Many practices would not be sustainable
We could easily be working for a big box lab at 50% of today average salary in just a couple years.

Stay tunned.
Not looking good IMO.
Congress wants to kick someone's ass and it is hospital based providers this session.

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[y2k_free_radical]

The out of network bill that came out of the House this week is distinctly unfavorable to hospital based providers.
It gives the payors all the power to set fees without negotiation.

Under this bill, they will likely be able to cut rates like Anthem is doing. There would be not recourse for providers.

The White House's statement this week is also very unfavorable to providers. They favor bundling all hospital payments for all hospital services.
You would have negotiate with the hospital for private insurance payment.

If either one of these go through it would be highly disruptive.
Many practices would not be sustainable
We could easily be working for a big box lab at 50% of today average salary in just a couple years.

Stay tunned.
Not looking good IMO.
Congress wants to kick someone's ass and it is hospital based providers this session.

The good news concerning reimbursements just keeps on coming.I might do better under socialized medicine.

 

[Med Director New England]

No doubt this is the direction. Bundled payments with little negotiation also coming. This will be bad for any oversupplied specialty and to inefficient systems (esp smaller hospital and hospitals with tons of unionized employees).

I think it won’t be long until a payer dictates we’ll pay 2500.00 (making this number up not sure what it actually will be) for a screening colonoscopy and the system will have to pay everyone involved for their contribution to the care of the patient challenging the system to squeeze costs everywhere possible. In a scenario like this probably better to be the RN , a relatively scarce commodity, in the endo suite supporting the procedure than the pathologist, in over abundance, reading the biopsies.

Just with lab copays on the patient I have seen many provides work to keep specimen counts lower by putting many biopsies in one jar instead of multiple. Imagine what will happen with bundled payments and everyone fighting for their share of the pie.

Even though the US is multi payer and technically fee for service b/c of the leverage payers have over MDs our system functions like a single payer system in many ways. This all wouldn’t bother me if I were paid back in full with interest for all of my student loans that I have paid off and if I could enter the federal pension system and buy back all years since I started practicing medicine.

 

[Spikebd]

No doubt this is the direction. Bundled payments with little negotiation also coming. This will be bad for any oversupplied specialty and to inefficient systems (esp smaller hospital and hospitals with tons of unionized employees).

I think it won’t be long until a payer dictates we’ll pay 2500.00 (making this number up not sure what it actually will be) for a screening colonoscopy and the system will have to pay everyone involved for their contribution to the care of the patient challenging the system to squeeze costs everywhere possible. In a scenario like this probably better to be the RN , a relatively scarce commodity, in the endo suite supporting the procedure than the pathologist, in over abundance, reading the biopsies.

Just with lab copays on the patient I have seen many provides work to keep specimen counts lower by putting many biopsies in one jar instead of multiple. Imagine what will happen with bundled payments and everyone fighting for their share of the pie.

Even though the US is multi payer and technically fee for service b/c of the leverage payers have over MDs our system functions like a single payer system in many ways. This all wouldn’t bother me if I were paid back in full with interest for all of my student loans that I have paid off and if I could enter the federal pension system and buy back all years since I started practicing medicine.

Agree! In the meantime we should continue to fight tooth and nail against these proposals and fight for patient care and our specialty.

 

[WEBB PINKERTON]

Exempt lists will be a growing fast.

Maybe this will kill off ROSE procedures for us once and for all. Look on the bright side!

 

[AZpath]

The Senate bill is just as a bad as the House bill. The White house is eager to sign too.

(This covers all ERISA health insurance.
Typically employer funded plans are covered by ERISA. )

Looks the default payment will be the Network Median payment determined by the insurance company data.
I think the data will be pretty easy to manipulate.
Payors are going to narrow their networks to force the median payments lower and lower.

I don't think a lot of small independent groups with a lot of employer funded insurance will do very well in a few years.
I expect they will drop the smaller contracts and just pay the network medium
Hospital and larger labs will be the only ones that have a chance at negotiating.
Good luck with that. Welcome to 50% of MC payments!

 

[dukeresident]

We’re getting screwed royally. The bad news just keeps coming.

 

[Torsed]

Sad times.

 

[LADoc00]

Read my story about Anthem and AB72 in California, which is very similar in legal doctrine as this national law. In the end they will have a 125% Medicare rate or something similar payors will be forced to pay on without arbitration or negotiation. There will be a number of ways to game this to your group's advantage.

 

[AZpath]

Tell how this could possibly be good? The bill that is likely to pass will give us the median network rate

 

[LADoc00]

Tell how this could possibly be good? The bill that is likely to pass will give us the median network rate

That wont happen, will likely be comprised to 125% Medicare rates. As I said we got this in Cali already.

 

[AZpath]

I could handle 125% of MC too.

The median network is what you don't want to see

 

[y2k_free_radical]

That wont happen, will likely be comprised to 125% Medicare rates. As I said we got this in Cali already.

So how is ANTHEM able to pay 50 % of medicare as is happening in MISSOURI

 

[AZpath]

Senate Health education in labor committee just passed this.


Lower Health Care Costs Act that addresses five broad policy areas - surprise billing, transparency, exchange of health information, public health, and prescription drug costs. Key hospital provisions include:

• Applying the median in-network rate ("rate setting") to resolve surprise billing disputes between provider and insurer.
• Banning various contractual clauses including those related to "gag", "anti-tiering/anti-steering", "all-or-nothing", and "most-favored nation" clauses.
• Establishing billing policies such as requiring providers to: give patients a list of all services received within 5 days of discharge; and bill patients within 45 days, otherwise the patient would not be required to pay.

Most of us will be screwed.
Look forward to the median network rates at 50% of MC just like Anthem.
You can not go out of network to collect and they don't have give you a contract

If you never wrote your Congressional representative and Senator now is excellent time to start
CAP has tools that helps automatically send letters on this issue. Use them now !
They will likely bring this to the Senate floor in a few days