ICD-10 Conversion Allows Insurance Companies and Pharmacy Benefit Managers the Ability to Push More Drugs and Make Bigger Profits-The Illusion of Better Care Didn’t Happen-Cat Is Out of the Bag

<p>Everyone now has made the big change to convert from ICD9 to ICD10 Coding for medical billing.  When all of this was taking place, many said it would really not improve care and so far, that’s what we have seen.  The big coding change has not any impact in the “real” world; however when it comes to the “virtual” world the impact has been pretty big for analytics with insurance claim data.  It was an effort to where doctors and hospitals had to change their billing codes to add thousands of more specific codes.  Sure we all laughed at some of the codes and what they represented and some that would rarely be used if at all.</p> <p>The big sleeping monster on all of this is the use in behavior monitoring with all patients.  When fee for service items are billed by doctors and hospitals, this is the first code that is used to determine a diagnosis.  The second code is the CPT code which determines what the line item payment will be.  The two work together and the US is the only country that has this massive correction between the two for medical<a href="https://lh3.googleusercontent.com/-tWBotw6Xue8/V68k18unLrI/AAAAAAABMy8/j0A7lc_9qDE/s1600-h/image%25255B7%25255D.png"><img align="right" alt="image" border="0" height="143" src="https://lh3.googleusercontent.com/-KbTmiuOWJSM/V68k2kRMBdI/AAAAAAABMzA/W2ZsaJMws7E/image_thumb%25255B3%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image" width="240"></a> providers to get paid.  Sure in other countries is may be observed, but in the US, the coding is literally taken to heart everywhere as this is a linear function that doesn’t include the fact that with each patient you have variables, as no two people are the same, so it’s a bit of what I call Quantitated Madness.</p> <p>Most people have not a clue on how this works, but insurance companies are using “machine” learning technologies to further this linear process, which does become flawed as we do have “variables” with every patient.  Now when you visit your doctor and they submit a claim, those claims are being analyzed against machine learning technologies, which I prefer to call “trending” as that’s a much less concerting term if you will.  Sure we all learn and gain knowledge by following trends and patterns, but now it’s gone over the top and flawed data is being kicked out to your providers all the time, and in essence it is being used as a platform to push drugs.  </p> <p>Now insurers with their doldrums of “risk” assessing that doesn’t stop, doctors are being graded with these ICD10 numbers included on the claim.  If a doctor states that diabetes may not be managed perfectly by the patient with an ICD10 code, they get notes back from the insurance company about “compliance” with analytics that may not be true.  In other words, the information that is coming back to them is that they are missing an opportunity to prescribe more drugs, and of course all of this goes into the “magic” formulas they use to “score” our doctors today.  If you ever wonder why your doctor is in network today and then gone tomorrow, this analytical scoring of doctors from how they code a medical bill is part of the story.  I wrote about that a while back, “The Secret Scoring of America’s Doctors”.  </p> <h5><a href="http://ducknetweb.blogspot.com/2014/08/the-secret-scoring-of-americas.html">“The Secret Scoring of America’s Physicians” - Algorithmic Math Models For Insurance Network Contractual Exclusions, Relating to MDs Who See Medicare Advantage Patients..</a></h5> <p>Ok, so you visit your doctor, discuss any chronic conditions and items you need to talk about related to better healthcare.  In order for the doctor or hospital to get paid for that service, they bill this information via an ICD10 code that describes the purpose of your visit.<a href="https://lh3.googleusercontent.com/-UUB5Z8eGbQY/V68k3d_DoyI/AAAAAAABMzE/fbJdGdO2TEM/s1600-h/image%25255B3%25255D.png"><img align="right" alt="image" border="0" height="142" src="https://lh3.googleusercontent.com/-fgOPxCW3l3M/V68k35A9qqI/AAAAAAABMzI/6o7nMdXN6Hg/image_thumb%25255B1%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image" width="451"></a>  Insurance have spent billions of dollars to create system that will take this billing, analyze it and then come back with so called “opportunities” for the doctor to evaluated.  I have included a screenshot here from Dr. Wes, who was kind enough to put this on Twitter so you can see what they are bombed with by the time the insurance company does all their expensive analytic processes.  In this example, the insurer (United Healthcare) is telling the doctor that the numbers, when crunched say that the patient is not at 80% compliance on taking their medications.  Again, this can be totally false as it is all based on a code which can be totally taken out of context.  This happens a lot today, not only in healthcare but in other businesses as well and that is how we end up with all these bias analytics. <p>Pay attention is this is the type of analytics that is being created about all of us and in this example, you can see, it’s clearly promoting a pharma agenda and of course we know United Healthcare has a big interest in this as OptumRX is their number one dollar producting revenue stream, more than Medicare Part D and their two other reporting groups.  Here’s what I wrote about the United first quarter and the second quarter was the same story with where the big money was coming in for 2016. <h5><a href="http://ducknetweb.blogspot.com/2016/04/united-healthcare-reports-1st-quarter.html">United Healthcare Reports 1st Quarter-OptumRX (Pharmacy Benefit Manager) Produces More Revenue Than Its Health Insurance Groups</a></h5> <p>The company has clearly made a change in their operation to focus on partnering with big pharma to profit as a priority.  If you were not aware, that is how United Healthcare got started in business in the 70s as the first pharmacy benefit manager in healthcare.  They later sold the company to a drug company and used the sale profits to buy insurance companies and began as a healthcare insurance company. <img align="right" src="http://lh6.ggpht.com/-3szEXZPRIqQ/U7qv_R169gI/AAAAAAABKxc/evT7Y_hxGEc/image121.png?imgmax=800" style="float: right; display: inline"> A couple years later, Express Scripts bought the company from the pharmaceutical firm and so Express Scripts was able to get all the magical analytics code that runs today, with even more compleities added.  Outside of this blog, many times over United Healthcare has been covered by many other articles that talk about the millions or billions the company makes selling your data as well. <h5><a href="http://ducknetweb.blogspot.com/2016/04/united-healthcare-reports-1st-quarter.html">United Healthcare Reports 1st Quarter-OptumRX (Pharmacy Benefit Manager) Produces More Revenue Than Its Health Insurance Groups</a></h5> <p>So when you look back on this big push for ICD10 conversion, it has not done anything to provide better care for patients with doctors, but in reality added another level of complexity so you could be further “scored” and “risk assessed” by insurance and drug companies.  Again, with using linear measurement standards you end up somewhat being “scored” or “graded” on this so called curve of machine learning, which may not represent your entire health picture at all but ends up being more flawed data that doctors have to deal with and an analytics platform to push more drugs. From the consumer side, you are “scored” on what the Pharmacy Benefit Managers “predict” you adherence and compliance will be. Read the link below to find out about the 300 metrics used, that actually Express Scripts bragged about that are proprietary and hide the bias, all for the sake of creating these flawed scores relative to your behavior.</p> <h5><a href="http://ducknetweb.blogspot.com/2015/06/medication-adherence-predictions-enter.html">Medication Adherence Predictions Enter the World of Quantitated Justifications For Things That Are Just Not True, Members of the Proprietary “Code Hosing” Clubs Out There Destroying Your Privacy</a></h5> <p>Here’s a link from the archives that tell about Express Scripts buying those “Ingenix” algorithms to score consumers on medication adherence and this was the root of it as PBMs went over the top with their “flawed prediction” software.</p> <h5><a href="http://ducknetweb.blogspot.com/2010/10/express-scripts-new-program-to-contact.html">Express Scripts- New Program to Contact and Predict Patients Who May Not Be Taking Their Medicine Based On IngenixAlgorithms–We Want the Revenue Please Don’t Stop</a></h5> <p>This further graduates to the retail pharmacists who fill our prescriptions and how they are graded on their pay for performance levels on how you are predicted to take your meds.  Sure this is always a work in progress chore and pharmacists over all do a good job, and the patient may be well in compliance but they worry too about this flawed data that “scores” them.  You read the link below and watch the videos on the threatening letters they receive if they give you a cash price that is less than your insurance co-pay is.  In other words, they get penalized for helping the consumer with price if it is not what the insurance company supplies.  Why?  They can’t track the data as efficiently if you pay cash.  <h5><a href="http://ducknetweb.blogspot.com/2016/06/the-truth-about-pharmacy-benefit.html">The Truth About Pharmacy Benefit Managers and Prescription Discount Cards–Created With Automated Algorithmic Processes That Enable Huge Profits-Consumers at Risk!</a></h5> <p>By the way, you cannot even get this “medication adherence prediction” score that is calculated about you from your “data” behavior as it is secret.  So you have two sides of this flawed at work, from the doctor side and from the pharmacy side with insurers beating both over the head with wanting them to further control your behavior.  We all know that one person can’t control another person, but this is the perception-deception being sold out there.  Education is still the best method and to rate and grade patients on flawed data analytics is just wrong and fraudulent.  <p>So there you have it, the big ICD10 change was not to provide better care for patients and has not done one thing to improve that as you can read the news every day, we are all paying for additional flawed analytics that go nowhere except into the profits of insurers and pharmacy benefit managers with perceptions of the data taken out of context and skewed to make everyone look worse than they are.  <p>All of this analytics work with claim data about you of course is all sold and CMS Slavitt (an Algo man, former Goldman banker and McKinsey consultant) is all over it with wanting <img align="right" src="http://lh6.ggpht.com/_v3zjJigoAPE/TLZdsFwnFqI/AAAAAAAAiIY/NIhj9oaZrLo/image_thumb%5B4%5D.png?imgmax=800" style="float: right; display: inline">to sell all this claim data as well so more companies can create even more flawed analytic scores about you so more software companies can jump into the “Code Hosing” game. Read more about that at the links below.  <h5><a href="http://ducknetweb.blogspot.com/2015/06/cms-chasing-wild-virtual-horses-big.html">CMS Chasing Wild Virtual Horses-A Big Distraction on the Hope of Finding Some “Algo Fairies” By Giving Entrepreneurs Access to Medicare Claims and Other Data…Marketing & Astro Turfing “The Sebelius Syndrome”..</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2016/01/cms-medicare-proposing-more-data.html"><strong>CMS Medicare Proposing More Data Selling of Both Private and Medicare Patient Claim Data - A New Dignity And Privacy Attack on Both Consumers and Doctors</strong></a></h5> <p>So the cat is out of the bag, ICD10 was a new avenue for analytics in healthcare and does not one thing to produce better care, but was rather one more form of Health IT software that all were required by law to invest in.  So a little satire, here, why even as a consumer even get out of bed in the morning…you’re already risk assessed to the hilt!  We have no value when you look at all this nonsense and we all seem to be a risk to the world anymore.  What happens next on Infusion compliance?  As you can see insurers are buying those companies up as well.  Will each vein be risk assessed next?  There’s a ton of cronyism at the link below as well to include a discussion on Loretta Lynch as one example being a former lawyer who represented United Healthcare with anti trust lawsuits so you can see she’s in on the game or the dupe, one of the two.  BD  <h5><a href="http://ducknetweb.blogspot.com/2015/11/optumrx-united-healthcare-buys-home.html">OptumRX (United Healthcare) Buys Home Infusion Company AxelaCare-Using Algorithms To Determine Your Care With Being Financed By A “Too Big to Fail” US Health Insurance Company…</a></h5>

ICD-10 Conversion Allows Insurance Companies and Pharmacy Benefit Managers the Ability to Push More Drugs and Make Bigger Profits-The Illusion of Better Care Didn’t Happen-Cat Is Out of the Bag

Everyone now has made the big change to convert from ICD9 to ICD10 Coding for medical billing.  When all of this was taking place, many said...

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OptumCare Doctors to Get Allscripts Medical Records EHR–Optum Continues to Buy More Practices and Manage More Doctors Through Independent Physician Associations, Many of Which They Own

<p>I’m starting to see more doctors in Orange County selling out their practices to United Healthcare’s Optum subsidiary.  Sometimes when patients go for their next appointment, in addition to see their doctor’s name on the door, it also now says OptumCare.  So now it appears at minimum <a href="https://www.optumcare.com/medical/locations/ca-orange-county/ocmg-huntington-beach.html"><img align="right" alt="WP_20160509_17_31_38_Pro" border="0" height="260" src="https://lh3.googleusercontent.com/-8J7WUJZ5Rz0/V6gUnXYM1OI/AAAAAAABMyg/p3uPnTCP6xc/WP_20160509_17_31_38_Pro%25255B7%25255D.jpg?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="WP_20160509_17_31_38_Pro" width="199"></a>that doctors practices that are owned outright by Optum will get Allscripts medical records and perhaps the affiliated doctors working for the Physicians Associations they own, such as Monarch Healthcare as an example.  The article was not explicit to explain enough about how this will work exactly.  If you click on the picture at the right, I did a snap shot of a new OptumCare Clinic in Orange County that was just opening and this is where a doctor recently sold his practice to Optum and they provided him with a physician’s assistant in his office and are running the operation.  Here’s a couple examples of the IPA affiliations at the links below. </p> <h5><a href="http://ducknetweb.blogspot.com/2011/08/united-healthcare-to-buy-huge-chunk-of.html">United Healthcare To Buy Huge Chunk of Orange County, California Managed Care Business with the Purchase of Monarch Healthcare–Subsidiary Watch</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2013/10/uc-irvine-affiliates-itself-with.html">UC Irvine Affiliates Itself With The Largely Managed And/Or Owned Orange County UnitedHealthCare Subsidiary Manifesto</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2014/05/memorial-healthcare-ipa-in-southern.html">Memorial Healthcare IPA In Southern California Has Been Merged Into MonarchHealthcare, a Wholly Owned Subsidiary of Optum Health, A United Health Company, “Lives and Providers Have Been Dropped From Inventory” At Memorial Healthcare IPA…</a></h5> <p>We all should probably know the squeeze is on the small practices to where the admistrative end of running a practice is under attack by the government with CMS and their new MACRA payment plan which is still up in the air as of this writing.  Practices of less than 24 doctors will pretty much be penalized and will not be able to sustain the cuts.  The new payment plan has no proof of concept and is just a model being put out there with a bunch of quantitated madness to again push more small practices out of business.  As an average, doctors who contract with United Healthcare get paid around 12% LESS THAN MEDICARE.  </p> <p>That will give you the idea of where all of this is headed.  In addition, the doctors who are affiliated via an IPA, Independent Physicians Association who are smaller practices no doubt will have to pay for the Allscripts EHR as wel.  I don’t know how it will work exactly for the “owned physicians” where Optum has bought them outright.  </p> <h5><a href="http://ducknetweb.blogspot.com/2016/05/the-rise-of-quants-again-this-time-in.html">The Rise of the Quants, Again! This Time In US Healthcare- Taming the MACRA Beast of Quantitated Madness For A Lot of Things That Are Probably Just Not True</a></h5> <p>In addition, there’s a lot of other interesting items taking place with Optum and Urgent Care centers as they have opened up some of their own and they also bought Med-Express, who runs urgent care centers and is also soliciting doctors to sell their practices to their company. <h5><a href="http://ducknetweb.blogspot.com/2015/04/optum-united-healthcare-buys-medexpress.html">Optum (United Healthcare) Buys MedExpress Urgent Care Business- 141 Full Service Clinics In 11 States–Company Advertises They Are In the Market to Buy Your MD Practice, As A “Too Big To Fail Insurer” Moves Forward With More Acquisitions</a></h5> <p>Other insurers don’t have the “fox in the hen house” with the Feds either like United does and has for a number of years and here’s one more example.  <h5><a href="http://ducknetweb.blogspot.com/2015/11/hhs-joins-optum-labs-as-research.html">HHS Joins Optum Labs as Research Partner–Back Peddles Support of FDA Sentinel Program That Does the Same Thing-More Impact from the Six Degrees of Bob Rubin Running Healthcare in the US</a></h5> <p>Below are a couple of links that tell you more about the secret fudning of $36 Million that was created to finance <a href="https://www.optumcare.com/medical/about-optumcare/health-care-providers.html"><img align="right" alt="image" border="0" height="99" src="https://lh3.googleusercontent.com/-Q5pZlaR9W4c/V6gUnz-UwhI/AAAAAAABMyk/ggkMWp9ssdU/image%25255B4%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image" width="240"></a>this entire subsidiary of Optum, Optum Clinics Holdings as well as the money raised, huge bond sale to by the Catamaran pharmacy benefit management company, which also increased their business as Catamaran had a 10 year contract with Cigna so under the OptumRX subsidiary, United Healthcare picked up a ton of revenue there.  I don’t know much about anti-trust but enrolling with one insurer and having a pharmacy benefit manager from another insurer seems to be cutting down competition in the prescription arena.  You can read more about the Clinic Care side of this in Southern California and link to what’s going on in other states <a href="https://www.optumcare.com/about-optumcare/health-care-providers/practice-models-locations/california.html">from here.</a>  This link appears to be additional practices in <a href="https://www.optumcare.com/medical/locations/ca-orange-county.html">Orange County that sold their practices to Optum.</a>  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/05/optum-clinics-holdings-new-subsidiary.html">Optum Clinics Holdings, New Subsidiary Incorporated In 2015 Raises Over 36 Million (Exchange of Shares) From Investors Unknown-Form D Used to Maintain Secrecy Of Who They Are For Now…</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2015/07/united-healthcare-having-big-bond-sale.html">United Healthcare Having a Big Bond Sale to Finance Purchase of Catamaran Pharmacy Benefit Management Company, Huge 10.5 Billion</a></h5> <p>Here’s what is being advertised to doctors…again probably at that 12% less than Medicare payment schedule.  Here’s a link to the “practice acquisition” page with one <a href="https://www.optumcare.com/about-optumcare/health-care-providers/howard-bland.html">doctor talking about how he sold out.</a>   I used to drive by that practice all the time on my way home a few years ago, and it’s not a new one.  </p> <p><a href="https://lh3.googleusercontent.com/-_1sgRxRunDo/V6gUoczPZbI/AAAAAAABMyo/fVn01w-QpsU/s1600-h/image%25255B9%25255D.png"><img alt="image" border="0" height="158" src="https://lh3.googleusercontent.com/-pe1wP13h0kI/V6gUoxeUBHI/AAAAAAABMys/0si9jM_5ID4/image_thumb%25255B4%25255D.png?imgmax=800" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" title="image" width="715"></a> <p>So now with Allscripts Medical Records, there will be more access to your data from the big conglomerate, that’s for sure.  Optum used to sell their own EHR called Care Tracker and they sold it off about a year or so ago.  Optum has been advertising for a while that they also want to be your medical records integrator, for AllScrips and a few other big companies. <h5><a href="http://ducknetweb.blogspot.com/2014/02/allscripts-ends-up-with-loss-for-2013.html">Allscripts Ends Up With a Loss for 2013 of $104 Million-United Healthcare Subsidiary Ready To Step In To Be An allscripts Implementer And Beyond…</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2013/11/united-healthcare-optum-insight.html">United Healthcare (Optum Insight Subsidiary) Wants To Be Your Allscripts, Epic And GE Centricity EHR Consulting Service Starting With Implementation And Beyond</a></h5> <p>So if you are a patient, be aware that many small practices are being bought by United Heatlhcare, and there’s also a bunch being purchased by large hospital systems as well.  When I took the picture above, in a small strip mall you had the OptumCare office on one side and a new Tenet MedPost Urgent Care Clinic opening up a few doors down, again a small strip mall, large enough for both?  BD <p> <hr> </p> <p>Health services company OptumCare, part of UnitedHealthcare subsidiary Optum, announced on Friday that it has tapped Allscripts TouchWorks suite as its electronic health records (EHRs) platform for its physician practices. Implementation will begin later this year, the company said. OptumCare serves more than 8 million people in 49 geographic markets. </p> <p>Allscripts will integrate its EHR and practice management software with the technology OptumCare’s physicians currently use. The combined technology and single platform will facilitate the integration of patient’s care across the ambulatory continuum of care, the company said.</p> <p><a href="http://stateofreform.com/issues/healthit/2016/08/optumcare-selects-allscripts-health-provider/" title="http://stateofreform.com/issues/healthit/2016/08/optumcare-selects-allscripts-health-provider/">http://stateofreform.com/issues/healthit/2016/08/optumcare-selects-allscripts-health-provider/</a></p>

OptumCare Doctors to Get Allscripts Medical Records EHR–Optum Continues to Buy More Practices and Manage More Doctors Through Independent Physician Associations, Many of Which They Own

I’m starting to see more doctors in Orange County selling out their practices to United Healthcare’s Optum subsidiary.  Sometimes when patie...

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