I don’t think this is putting anyone in in the “poor” house as almost everyone knows that Part D Medicare is some of the most profitable business out there for HMOs, managed care organizations, and IPAs. Here’s a post from a couple months ago where this small Venture Capital backed HMO Carrier made profits of 1 Billion 
for 2009. Do you think anybody is hurting here. Just for comparison, big pharma company Merck posted profits of 460 million last year.
Bravo Health – Venture Capital Backed Medicare Senior Health HMO Carrier Sees Profits of 1 Billion for 2009
However, in speaking with an IPA not too long ago, they told me they break even on the commercial HMO part of their business and the Medicare Part D billing “is” their only profit since the commercial side payments have been drilled down so low. Is there a lot of profit from the government being made by commercial businesses, it sure looks that way. We have an HMO in California called CareMore and that is all they do too, Part D with Medicare.
CareMore Live On TriZetto's Clinical CareAdvance System Algorithms - Healthcare Business Intelligence
CareMore Health Plan Invests in Business Intelligence for Acute and Chronic Illness Management
Just a short while back, 2008, HMO carriers in California made profits of 4 billion. CareMore is also working at drilling down the algorithms of cost and you can read more at the link below, which is basically talking about a “hospitalist” type of doctor that makes house calls for seniors.
Health Plan Hospitalists Keeping Re-Admissions Down by “Leaving” the Hospital – “The Extensivist”
Private equity firms are investing and as a matter of fact the big company CareMore has partnered with is ran by a Private Equity company in the UK. They are also
all about numbers and algorithms to create profits so you can read about what they are calling their “killer” PHR they are offering with Payer information and access to who in total, I’m not quite sure. Trizetto partners with Ingenix, the wholly owned subsidiary of United Healthcare.
TriZetto Group, Owned by Apax Partners-London Based Private Equity Firm, Rolls Out Payer Based PHR
Healthcare claim denied, there’s an app for that in managing denial processes, quote from the website below, “streamline” denial management. Makes you wonder as a consumer at times when disputing denied claims how you can stack up your information as you need to just get care, but this is the reality of some of the processes denied claims go through and the business intelligence strategies created for ultimate risk management that consumers have to battle, the algorithms of healthcare for profit.
“The Emdeon Denial Manager solution allows providers to organize and manage remittance inventory; helps staff arrange, prioritize and monitor denials and 
underpayments; and allows the accurate reporting and viewing of the denied and adjusted amounts. With the information produced by Emdeon Denial Manager, providers streamline the denial management process by determining root causes, patterns and process breakdowns responsible for denials, and establishing corrective steps to prevent future revenue loss or delay.”
With all the hatches coming down you can expect the algorithmic parameters to get tighter too so patient and doctors may both be seeing more red tape and difficulties in getting some claims paid.
Healthcare Reform Bill – Expect “Fraud Algorithm” Use to Increase With “Scoring” the Insured With Our Leadership Trapped Embellishing Old Paradigms
The link above will explain a bit more of how some of the processes work. BD
April 6 (Bloomberg) -- UnitedHealth Group Inc. and Humana Inc. are among the insurers who will receive the same payment rates in 2011 as this year for administering health plans for the elderly, according to rules issued by Medicare.
The health-care overhaul signed by President Barack Obama last month mandated a freeze in payments in the Medicare Advantage program, the U.S. Centers for Medicare & Medicaid Services said in a statement posted yesterday on its Web site. Before the announcement, the program was expected to account for 14 percent of earnings next year at Minnetonka, Minnesota-based UnitedHealth and 42 percent for Louisville, Kentucky-based Humana, Dave Shove, a BMO Capital Markets analyst based in New York, said March 31 in a note to clients
Medicare Payments Frozen for UnitedHealth, Humana (Update2) - Bloomberg.com
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