Health Insurers in California Prepare to Negotiate Contracts with “Covered California” the Branded Name for the California Insurance Exchange–Complexities of Contracts Today Running on Corporate Servers 24/7 Opens the Door for More Sophisticated Algorithms
Health insurance companies live off those “algorithms” for profit as defined in their business models. Speaking of business models, lets not forget that insurers are traded on the open market and they have Quants just like the banks do so if you want to see some of the fiction that goes into the modeling, check this out and watch the video. This is real life with quantitiave numbers that contain items out of the air at times and no guarantee on the accuracy, but they are designed to make money. It was also in the news today that HHS gives states more time to “design” insurance exchanges, heck the time is not needed for “designing” but rather for duking out contracts with insurance carriers:) This stuff about rising to the occasion that I read today seems to be off base.
From the CMA:
“According to the notice, Blue Cross will be creating a new provider network called the "Anthem Individual/Exchange Network," which will serve both individuals who purchase coverage through the exchange and individuals who purchase coverage from Anthem Blue Cross in the individual market outside of the exchange. In other words, the fee schedule would apply to all individual business, whether bought on or off of the exchange.
Blue Cross has clarified for the California Medical Association (CMA) that this fee schedule change will not apply to Small Business Health Options Program (SHOP) business purchased through the exchange.”
“Physicians who do not wish to participate in this network must notify Blue Cross of their intent to opt out by December 31, 2012. Opt out notices should be in writing and sent via certified mail, return receipt to the address specified in Section VI of the amendment.”
So as you can read, a certified letter must be sent by the doctors to opt out by the end of this year or they are in by default. Now let’s not forget it’s getting close to the time of year when Congress has to deal with the the SGR reduction of 30% by Medicare and do what ever they are going to do. Putting it off without a fix is making it worse.
Here’s a quote from a doctor from my mailbox today…
”….I have always done pro bono work (i.e. free care) to uninsured patients in the hospital. Now these numbers are growing and I am doing more free work than ever. You would think the government should take this into account and be more compassionate with us instead of trying to kick us while we are down.”
So in a couple of years, who will have insurance that can provide enough doctors in network for patients? That’s a good question right now. We also have to remember that some of the IPAs are owned by insurance companies and how’s that going to work? What if they want to opt out from the insurer that owns the IPA they are a member of for one example?
Best I can say here is that it’s time for a single pay option as by the time the complex stipulations are lined out nobody will know who covers what. Besides there are several private exchanges popping up so it’s not like there’s a shortage on “where” one can buy insurance. If insurers are going to pay doctors 30% percent less on their end if you are a consumer who bought insurance from an “exchange” well, how many will accept the lower compensation or how many will opt out in time. I can see this leading up to a lawsuit on the “opt out” clause here if someone decides to pursue it and if this goes through with Blue Cross, well you could almost bet that the other carriers will do the same or maybe worse.
Here’s a private exchange owned by WellPoint for example and will the doctors who use “their exchanged” get paid less like the State of California exchange…yes indeed more good questions as the “poke in the fanny” contract annihilation continues.
WellPoint & Partners Buy Bloom Private Health Insurance Exchange From Their Own Venture Capital Company (Sandbox) –Subsidiary Watch
You wonder is California going to change their law to allow hospitals to directly hire doctors? When the expense of keeping up a practice no longer generates an adequate income the doctors have to go somewhere, so what’s next an “exchange doctor group”. Sure that sounds a bit out there but so does half of everything else out there today with insurance contracts. Once the doctors opt out I don’t know if they have a change of heart and can opt back in or not? If the insurers don’t make it on policy sales they have Health IT to fall back on as they are all gobbling up technology companies right and left and again with creating their own private exchanges and if the public is aware that their doctors are going to get paid less, where does this leave all of this? Do we need exchanges by government? When it was designed and the law was passed, things were different but by today’s standards of complexities, it might already be outdated.
It seems like hospitals are on the edge of “becoming technology centers that have medical licenses, you think? BD