NY Presbyterian Gets Paid $97K for 28fx Prostate...

[TheWallnerus]

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...On a Medicare Advantage patient. Ordinarily, other hospitals and freestanding places will be getting ~$17K max (very few small places have the ability to negotiate >100% Medicare rate)... and that's true even if they're doing 45 fraction IMRT.

They also get ~$12K per SBRT fraction on MA patients.

"End of tweet" as Jimmy Caan used to say.

 

[medgator]

...On a Medicare Advantage patient. Ordinarily, other hospitals and freestanding places will be getting ~$17K max (very few small places have the ability to negotiate >100% Medicare rate)... and that's true even if they're doing 45 fraction IMRT.

They also get ~$12K per SBRT fraction on MA patients.

"End of tweet" as Jimmy Caan used to say.

Why would MA agree to pay that? Usually they are trying to bone freestanding centers by paying less than Medicare rates and pocketing the difference

 

[RickyScott]

...On a Medicare Advantage patient. Ordinarily, other hospitals and freestanding places will be getting ~$17K max (very few small places have the ability to negotiate >100% Medicare rate)... and that's true even if they're doing 45 fraction IMRT.

They also get ~$12K per SBRT fraction on MA patients.

"End of tweet" as Jimmy Caan used to say.

Where is the original negotiated price list?

 

[TheWallnerus]

Why would MA agree to pay that? Usually they are trying to bone freestanding centers by paying less than Medicare rates and pocketing the difference

I do not have an answer. Why did the Beatles break up. Why is there more matter than antimatter in our universe. Why is Elon Musk throwing all his money in a fire. Why.

 

[deleted1116990]

And the doctor gets paid $1500 of that $98,000 and is told by admin with a straight face that any more than that would be illegal because it would be above "fair market value."

 

[imhopeful432]

...On a Medicare Advantage patient. Ordinarily, other hospitals and freestanding places will be getting ~$17K max (very few small places have the ability to negotiate >100% Medicare rate)... and that's true even if they're doing 45 fraction IMRT.

They also get ~$12K per SBRT fraction on MA patients.

"End of tweet" as Jimmy Caan used to say.

Which MA plan is paying that much to them? All of them? Would love to see a source...

 

[deleted1116990]

Why would MA agree to pay that? Usually they are trying to bone freestanding centers by paying less than Medicare rates and pocketing the difference

Or using Optum and Evicore to stall until the patient is dead so they don't have to pay at all.

MA plans are one of the biggest scams in the scammiest industry.

 

[RickyScott]

Or using Optum and Evicore to stall until the patient is dead so they don't have to pay at all.

MA plans are one of the biggest scams in the scammiest industry.

How are they more “scammy” than the outright thievery of NY Presbyterian, a third tier department? Medicare advantage has profit capped at a set amount 10-15% by law.

 

[TheWallnerus]

Which MA plan is paying that much to them? All of them? Would love to see a source...

Source is me. Best I can do.

 

[TheWallnerus]

How are they more “scammy” than the outright thievery of NY Presbyterian?

MA is the game. NYP is the player. You know what they say about players and games.

 

[NotMattSpraker]

MA is the game. NYP is the player. You know what they say about players and games.

 

[Fpg1245]

I have stopped hypofx of prostates because of this. The big places can do it and still make a killing. I do it and it doesn’t matter it just means I’ll be working for the big place faster and my Dept won’t function.

 

[radoncftw]

I have stopped hypofx of prostates because of this. The big places can do it and still make a killing. I do it and it doesn’t matter it just means I’ll be working for the big place faster and my Dept won’t function.

conventional fractionation is the gold standard 🙂

 

[elementaryschooleconomics]

Source is me. Best I can do.

I feel like the people who don't believe this thread aren't going to change their mind, but for what it's worth, I can vouch for the numbers.

 

[communitydoc13]

I do not have an answer. Why did the Beatles break up. Why is there more matter than antimatter in our universe. Why is Elon Musk throwing all his money in a fire. Why.

Medicare Advantage: A Policy Primer

As Medicare Advantage nears becoming the dominant coverage form, evaluating beneficiaries’ experiences and its sustainability is crucial. Learn more.

www.commonwealthfund.org

I don't have an answer, but I have a hypothesis.

1. NYP is such a large system that they can leverage the MA insurance companies. "Finance bros, NYPD, school teachers etc. want a plan that get's them care at NYP. If you want to be able to include us in network, this is what you have to pay."

2. The MA plan kind of shrugs at this sort of stuff because of the old mandated loss ratio.

Per the link above:

Medical loss ratios. Since 2014, Medicare Advantage and Part D prescription drug plans have been required to have “medical loss ratios” no lower than 85 percent. This means that plans’ administrative expenses and profits, or margins, can be no higher than 15 percent of the total revenues that plans receive from the federal government (in the form of payments) and enrollees (in the form of premiums).

The higher the total cost of care, the larger the absolute acceptable margin. The math may dictate that: all those premiums from such and such sector of our community more than make up for the excess negotiated cost of service and the total increase in cost allows for a larger profit in terms of absolute number).

Just the usual f@3k@5y that large organizations participate in.

 

[sloh]

Medicare Advantage: A Policy Primer

As Medicare Advantage nears becoming the dominant coverage form, evaluating beneficiaries’ experiences and its sustainability is crucial. Learn more.

www.commonwealthfund.org

I don't have an answer, but I have a hypothesis.

1. NYP is such a large system that they can leverage the MA insurance companies. "Finance bros, NYPD, school teachers etc. want a plan that get's them care at NYP. If you want to be able to include us in network, this is what you have to pay."

2. The MA plan kind of shrugs at this sort of stuff because of the old mandated loss ratio.

Per the link above:

Medical loss ratios. Since 2014, Medicare Advantage and Part D prescription drug plans have been required to have “medical loss ratios” no lower than 85 percent. This means that plans’ administrative expenses and profits, or margins, can be no higher than 15 percent of the total revenues that plans receive from the federal government (in the form of payments) and enrollees (in the form of premiums).

The higher the total cost of care, the larger the absolute acceptable margin. The math may dictate that: all those premiums from such and such sector of our community more than make up for the excess negotiated cost of service and the total increase in cost allows for a larger profit in terms of absolute number).

Just the usual f@3k@5y that large organizations participate in.

If you only get a piece of the pie, just make the pie larger!

 

[RickyScott]

If you only get a piece of the pie, just make the pie larger!

Medicare advantage has tiers of plans in my region. Some plans have monthly fees of several hundred dollars and better coverage.

 

[IonsAreOurFuture]

Or using Optum and Evicore to stall until the patient is dead so they don't have to pay at all.

MA plans are one of the biggest scams in the scammiest industry.

I think MA plans should be outlawed, or at least prohibited from using the name Medicare at all.