Healthcare organizations and companies are going to face a “watershed” 2009, according to a new report from PricewaterhouseCoopers LLP’s Health Research Institute.
The institute took a look at nine pressing issues for health executives and policy makers.
The institute’s No. 1 issue isn’t a surprise: the economy, which is beginning to affect even the stalwart healthcare industry.
“Although the health industry historically has been less vulnerable to economic downturns than other industries, the disrupted economy will hit healthcare in 2009,” the institute said.
Hospitals and providers,from family doctors to dentists,will also have higher bad-debt levels and see drops in elective procedures as consumers tighten the purse strings, according to the institute. Even commercial insurers are paying less money to hospitals and healthcare providers because of drops in enrollment.
The number of underinsured people is quickly overtaking uninsured people, according to Price- waterhouseCoopers. Fig-ures show that an estimated 25 million American adults are considered underinsured, up 60% from 2003, which could affect payments to hospitals.
“With some, but not enough, health insurance, the underinsured often can’t or won’t pay the high deductibles and co-pays for the services they need,” the report said.
PricewaterhouseCooper also predicted that hospitals will have to meet certain performance standards in order to get paid, noting that Medicare, Medicaid and insurance companies are increasingly basing reimbursement on those standards.
“In 2009, healthcare providers will have to get serious about not only improving performance, but documenting it,” the institute said.
The federal Centers for Medicare and Medicaid Services have proposed adding a new index, called the total performance score, to rate its hospitals. If Congress goes along with it, regulators would replace a current quality of care reporting system with one under which Medicare could withhold 2% to 5% of its reimbursement to hospitals if they aren’t up to snuff.
The PricewaterhouseCoopers report wasn’t all bad news.
The report contains some good news for preventive health advocates, predicting that drug makers, regulators and nonprofit benefactors will push for preventive health in 2009, “making vaccines one of the few bright spots.”
Court Rules on Billing
Some Orange County group medical practices and a state association are cheering a recent ruling that bans “balance billing” of patients for hefty unpaid emergency room bills.
Earlier this month, Sacramento Superior Court Judge Michael Kenny upheld regulations from the state Department of Managed Health Care that banned balance billing, which charges patients in one lump sum for any services not covered by insurance.
Balance billing situations usually occur when a patient receives emergency healthcare at a hospital that’s not part of a list of the patient’s network providers. So-called “out of network” doctors who aren’t bound by what’s customarily paid under insurance contracts often seek payment on a balance that’s not covered by what an insurer is willing to pay. Hospitals and ER doctors who can’t get paid by insurers often seek a direct payment, sometimes for thousands of dollars, from patients.
“I have long thought of balance billing as being an unfair practice directed at defenseless patients,” said Keith Wilson, chief executive of Talbert Medical Group of Costa Mesa. “Bot-tom line, it is unfair to stick the unknowing insurance-carrying patient with the cost of the uninsured or underinsured just because you can.”
Gov. Arnold Schwarzenegger directed the Department of Managed Health Care to end balance billing two years ago. The department then drafted the rules, which went into effect Oct. 15.
The California Association of Physician Groups’ Chief Executive Donald Crane called the ruling “phenomenal news.”
The court’s decision “will ensure that patients don’t get stuck with their bill when their medical providers can’t agree on a sensible payment solution,” Crane said.
On the other side of the dispute, the California Medical Association has said it’s likely to appeal Kenny’s ruling. The medical association and the California Hospital Association contend that the judge’s order could undermine networks and agreements already in place between insurance companies and their member hospitals.
Bits and Pieces:
Lisa Flanagan and Orhan Nalcioglu, a pair of scientists at the University of California, Irvine, have received grants totaling nearly $1.6 million to develop advanced stem cell sorting and tracking devices aimed at improving therapies for people with neurological disorders, including Alzheimer’s and Parkinson’s diseases. The scientists received their money from the California Institute for Regenerative Medicine Prescription Solutions, an Irvine-based unit of UnitedHealth Group Inc., said it is going to provide “e-prescribing” services through a deal with SureScripts-RxHub LLC. Prescription Solutions is a pharmacy benefit management company that UnitedHealth got in its 2005 purchase of PacifiCare Health Systems, which was based in Cypress.
