Doctors In Network Leave United Healthcare–Tired of Getting Paid At Rates 12% Less Than Medicare…

<p>This problem is expanding into Kentucky now.  I have heard it for years in California with different doctors groups over and over complaining that their net reimbursement from United Healthcare is less than Medicare.  For those why buy insurance plans from exchanges, in many areas United pays somewhere between Medicare and Medicaid rates and that they have published themselves.   In California, complex contracts are used as part of the tools to keep the compensation low.  We keep reading all the time about the expense of doctors and a while back there was a study that came out and it said doctors are not that expensive compared to all the other costs in healthcare. </p> <p>So if you do find your doctor not in network with United, this could be part of the problem, being paid at rates<img title="image" 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" border="0" alt="image" src="http://lh3.googleusercontent.com/-yYujzjDKb74/Vbr8InAyD1I/AAAAAAABMfI/sN7Rf3pHmkk/image%25255B3%25255D.png?imgmax=800" width="251" align="right" height="106" /> that are 12% average less than what Medicare pays.  Of course, our current CMS head, Andy Slavitt drove this payment factorization to pay doctors less during his time at United Healthcare, so if confirmed at Head of CMS, that’s what’s there for those who are members, paying doctors even less and dumping more cost to the consumer.  The doctors in this group said they have not had a raise in 6 years with United.  Sometimes doctors are accepting less than Medicare and still get fired from United if the algorithmic formulas United uses says no, so they get fired by the algorithms as well.  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/02/united-healthcare-extending-narrow.html">United Healthcare Extending Narrow Networks in California–More Secret Scoring of Doctors in the US–Telling The Doctors If They Are “Allowed” To Be In Network…</a></h5> <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>The company also has a law firm in New York looking into the reimbursement issues.</p> <h5><a href="http://ducknetweb.blogspot.com/2014/06/law-firm-investigating-unitedhealthcare.html">Law Firm Investigating UnitedHealthCare Claim Payments in New York Stating Under-Reimbursement By Manipulating Algorithmic Benefit Calculations…</a></h5> <p>A couple  yeas ago the American Academy of Family Practice doctors took up this issue as well with United paying doctors at at rates less than Medicare, so it’s all over the US as an issue.  Don’t be fooled anymore and think that commercial insurers make up for the low payments of Medicare as they don’t always anymore.  There’s enough here in this post to substantiate that.  </p> <h5><a href="http://ducknetweb.blogspot.com/2014/07/aafp-says-were-not-going-to-take-it.html">AAFP Says We’re Not Going To Take It Anymore With Optimization of Provider Networks - Specifically United Healthcare’s Doctor Dumping That Disrupts Continuity of Care</a></h5> <p>Is there any reason why doctors are not really happy with United?  Here a couple years ago they put out an article telling the Feds to aggressively manage seniors and they are trying not only manage seniors but everyone else it seems.  BD</p> <h5><a href="http://ducknetweb.blogspot.com/2013/01/united-healthcare-issues-another-study.html">United HealthCare Issues Another Study, This One Telling Government To Aggressively Manage Medical Care For Seniors-An Area Where A Large Chunk of Their Revenue Comes From Today, Managing Care</a></h5> <p>It’s really not fair to the other insurers as well to have this United/Optum monopoly at HHS and CMS that exists today and has been around for years.  CMS now is stuck with a lot of the mentored United models that are not working so well as that’s all they do is numbers when it comes to insurance.  BD  </p> <p> <hr />Local doctors who are part of Highland District Hospital’s Professional Services Corporation will no longer be part of the United Healthcare network because they say United’s reimbursement rates have not been increased in six years.</p> <p>The doctors say the rates have remained unchanged even after three years of negotiations, and that current rates are, on average, 12 percent lower than even Medicare rates as well as the rates paid by most other commercial health insurance carriers.</p> <p><a href="http://timesgazette.com/news/1458/insurance-clock-ticking">http://timesgazette.com/news/1458/insurance-clock-ticking</a></p>

Doctors In Network Leave United Healthcare–Tired of Getting Paid At Rates 12% Less Than Medicare…

This problem is expanding into Kentucky now.  I have heard it for years in California with different doctors groups over and over complainin...

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CVS and IBM Watson Project–Please Make It Stop-13 Quarters of Declining Profits for IBM, Is This Is What We Get, More Algorithms Biting Us Constantly So More Data Can Be Mined and Sold Resulting In Excess “Scoring” of US Consumers..

<p>When IBMWatson first came out I thought it was great and still do for cancer research and other areas requiring deep data mining to find cures, but this, with “excess scoring” and selling of data mining has reached the limit.  If you read the article they don’t even know what<img title="image" style="border-left-width: 0px; border-right-width: 0px; background-image: none; border-bottom-width: 0px; float: right; padding-top: 0px; padding-left: 0px; margin: 0px; display: inline; padding-right: 0px; border-top-width: 0px" border="0" alt="image" src="http://lh3.googleusercontent.com/-fWkVaI-dEME/VbnKmH7ZnYI/AAAAAAABMec/cVNo-PTv9rU/image%25255B2%25255D.png?imgmax=800" width="187" align="right" height="63" /> they might find or what they are doing.  Why spend all this money?  CVS is making money hand over fist and the Affordable Care Act Czar Nancy DeParle sits on their board raking in the money for goodness sakes.  </p> <p>So if you don’t have any idea of what you are doing with this deep mining and cognitive technology, why do it?  Once this starts up, you’ll never find me in a CVS Minute Clinic, which I once thought were pretty cool, but adding on these big data lakes with clinicians who barely have enough time as it is, is not the answer.  I don’t like the fact that CVS is putting independent  pharmacies out of business at all.  You can read more about those tactics here.  You know what, these independent pharmacies never sold tobacco either, so knock off the marketing on that end of things as I never went in a CVS store to buy those products anyway, I want a prescription filled professionally and everything else in the store is just the side business.  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/06/cvs-buys-independent-pharmacy-picks-up.html">CVS Buys Independent Pharmacy, Picks Up A Slew of 7000 Ready Made Prescription Customers With Data To Mine and Sell…</a></h5> <p>When we can, we all avoid the “rewards” program as we know that adds profits to the approximate $2 billion that CVS makes <img title="image" style="border-left-width: 0px; border-right-width: 0px; background-image: none; border-bottom-width: 0px; float: right; padding-top: 0px; padding-left: 0px; display: inline; padding-right: 0px; border-top-width: 0px" border="0" alt="image" src="http://lh3.googleusercontent.com/-GWMLeysyjBU/VbnKm3DlvII/AAAAAAABMek/bamusDxRrpk/image%25255B6%25255D.png?imgmax=800" width="191" align="right" height="83" />selling our data every year.</p> <h5><a href="http://ducknetweb.blogspot.com/2015/04/cvs-to-share-more-medication-adherence.html">CVS to Share More Medication Adherence Love With New Contracts–Will Have More Data to Sell…</a></h5> <p>So now that IBM is losing sales, we have this now to mine and sell our data as well.  Why in the heck doesn’t IBMWatson go to Congress and get our lawmakers to use their technology as that’s a huge need instead of needling US consumers and scoring up backwards and forwards with all types of data.  This is over the top and its exactly why the opportunities in the US are not there anymore, you’re scored out of any opportunities with data miners and sellers that just want to make money.  Now read this next link and CVS uses this software too, you are an OUTLIER now if you pay cash.  The software even tells the pharmacists, go after those OUTLIERS and bring your scores up.  This is not hear say either, this post was from a conversation with a real pharmacist with all the flawed data floating into their system with using “predictive scoring” that’s loaded with tons of error bars and defaults you to “non compliance”.  This is no way to get better care! </p> <h5><a href="http://ducknetweb.blogspot.com/2015/07/patients-who-pay-cash-when-filling.html">Patients Who Pay “Cash” When Filling Prescriptions Are Now Called “Outliers, Pharmacists Required to Fix Outliers as They Show Up As Non Medication Adherence Compliant With 5 Star Systems Full of Flawed Data…</a></h5> <p>Take IBMWatson into the science area and keep using it to find cures for cancer and not this “scoring and monitoring” <a href="http://lh3.googleusercontent.com/-l8tRJ4RZJU0/VbnKnnDosHI/AAAAAAABMes/1ouUImTbB7M/s1600-h/image20%25255B5%25255D.png"><img title="image20" style="border-left-width: 0px; border-right-width: 0px; background-image: none; border-bottom-width: 0px; float: right; padding-top: 0px; padding-left: 0px; display: inline; padding-right: 0px; border-top-width: 0px" border="0" alt="image20" src="http://lh3.googleusercontent.com/-hztLH2vs7FU/VbnKos5BlKI/AAAAAAABMe0/TwKmDFjKaQM/image20_thumb%25255B2%25255D.png?imgmax=800" width="212" align="right" height="79" /></a>of consumers as we are tired of thousands of algorithms constantly biting us and predictions that are way off base.  Linear data does not take into account the “real” world and that’s what’s wrong with a lot of the “scoring” systems.  Financial Quant Paul Wilmott says it the best with a simplified explanation of why it will never be 100 bottles of beer as the surroundings and conditions change and the same is true for each patient.  This same thought is true in healthcare and yet we keep ending up with Quantitated Justifications for things that are not true.  Scroll down and watch video #1 in the footer of this blog for more on that topic and see how you get duped with numbers.  By the way if you like this clip, watch video #2 in the footer for the entire documentary about Quants.  You might as well learn up as that’s who’s designing your health insurance policies and reimbursements today for healthcare.  </p> <p><object height="300" width="425"><param name="movie" value="http://swf.tubechop.com/tubechop.swf?vurl=ed2FWNWwE3I&start=149&end=235&cid=2520036"></param><embed src="http://swf.tubechop.com/tubechop.swf?vurl=ed2FWNWwE3I&start=149&end=235&cid=2520036" type="application/x-shockwave-flash" allowfullscreen="true" width="425" height="300"></embed></object></p> <p>I can’t begin to even state how miserable this “scoring for profit” is making US consumers but we are tired of being “scored” with analytics that have no science and are just somebody’s proprietary formulas.  Next video gives you an idea on how economists fail.</p> <p><object height="300" width="425"><param name="movie" value="http://swf.tubechop.com/tubechop.swf?vurl=ed2FWNWwE3I&start=1962&end=2000&cid=2520137"></param><embed src="http://swf.tubechop.com/tubechop.swf?vurl=ed2FWNWwE3I&start=1962&end=2000&cid=2520137" type="application/x-shockwave-flash" allowfullscreen="true" width="425" height="300"></embed></object></p> <p>People do not work the way that some of these software models are designed.  Again work on genetics, cancer, with IBMWatson and get the cognitive scoring algorithms off our backs!  Use medical information in a clinical surrounding and stop with this excess scoring and the hope that you might just find something.  Here’s a short clip from Video #2 in the footer talking about financial models and the same applies for healthcare…people don’t work that way.  </p> <p><object height="244" width="425"><param name="movie" value="http://swf.tubechop.com/tubechop.swf?vurl=ed2FWNWwE3I&start=1700&end=1777&cid=6194999"></param><embed src="http://swf.tubechop.com/tubechop.swf?vurl=ed2FWNWwE3I&start=1700&end=1777&cid=6194999" type="application/x-shockwave-flash" allowfullscreen="true" width="425" height="244"></embed></object></p> <p>So can we please curb the madness here and stop putting all of us consumers through algorithm hell with trying to make some broken models work!  It’s not our fault that IBM sales are declining for the last 13 quarters and yet we are be punished by the excess scoring system that seems to live in the US as it makes money selling data.  I mean this stuff goes all the way up to the top with our President thinking quantitation of everything works and it doesn’t.  This is not going to improve outcomes, people working with people will improve outcomes.  I used to write software so I know what is possible and all software of course is not bad and there’s a lot of good stuff out there that makes us productive and turn out good work and idea, but this is not it!  </p> <p>This is more or less consumers feeling the brunt of IBMs drooping sales and someone along the line got creative and<a href="http://www.ducknet.net/attack-of-the-killer-algorithms/"><img style="border-left-width: 0px; border-right-width: 0px; background-image: none; border-bottom-width: 0px; float: right; padding-top: 0px; padding-left: 0px; display: inline; padding-right: 0px; border-top-width: 0px" border="0" src="http://lh3.ggpht.com/-6HDDm04lOwA/Ts0zq-EuFHI/AAAAAAAA4d8/nMT-KL0JEDY/image_thumb%25255B12%25255D.png?imgmax=172" width="191" align="right" height="89" /></a> thought this would be a good place to sell their technology, it’s not.  It hurts people with “excess scoring”.  Again take the IBMWatson technology back over to genetic studies, work on curing cancer, but get this IBMWatson “scoring” algorithms off our ass.  I can’t think of a better way to say it.</p> <p><em> </em><a href="http://www.youcaring.com/other/help-preserve-our-privacy-/258776"><em>Actually visit my campaign on indexing and licensing data sellers</em></a> and IBMWatson would be right in the thick of it.  If we could only see what companies and banks were selling out data, we might fall off our chairs and this is not a good place for this technology.  I’m to the point now to where I could care less if I ever step foot in a CVS store again.  It’s over the top and we need competition and employees who have systems they can work with, and this is broken model from day one, so please stop the excess scoring here and harassment of consumers.  It’s not our fault that IBM spent too many years buying back stock instead of investing more in the company.   BD  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/06/operation-perception-deception-into.html">Operation “Perception-Deception” Into Full Swing in the US, With Killer Algorithms, Algo Fairies, Algo Duping, The Grays, and Of Course, Flags As Consumers Confuse Virtual World Values With the Real World…</a></h5> <hr />IBM is teaming up with CVS Health to harness the power of the Watson supercomputing brain to transform how the care of patients with chronic conditions is managed. <p>Under a deal expected to be announced Thursday, the companies will work together to develop a system that would be able to provide better personalization of care, prevent the use of unneeded and costly interventions -- even predict health declines for a wide range of conditions including heart disease, diabetes and obesity.</p> <p>Troyen A. Brennan, chief medical officer for CVS Health in an interview that no specific product or timeline has been worked out, but that the first stage would be to jointly develop intelligent algorithms and test them to see if they helped improve patient outcomes. He said he was hopeful some "realistic interventions" could be identified in one to two years.</p> <p>Shahram Ebadollahi, chief science officer and vice president of innovation at Watson Health for IBM, said he hopes the technology developed through the partnership will help create an integrated, seamless system where every health care professional a patient encounters would have access to the most up-to-date information about a patient and the tools to be able to make sense of the information.</p> <p><a href="http://www.washingtonpost.com/news/to-your-health/wp/2015/07/30/next-stop-for-ibms-watson-supercomputer-your-local-cvs-pharmacy/">http://www.washingtonpost.com/news/to-your-health/wp/2015/07/30/next-stop-for-ibms-watson-supercomputer-your-local-cvs-pharmacy/</a></p>

CVS and IBM Watson Project–Please Make It Stop-13 Quarters of Declining Profits for IBM, Is This Is What We Get, More Algorithms Biting Us Constantly So More Data Can Be Mined and Sold Resulting In Excess “Scoring” of US Consumers..

When IBMWatson first came out I thought it was great and still do for cancer research and other areas requiring deep data mining to find cur...

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United Healthcare Finds Yet Another Way to Track You At the Grocery Store–Healthy Savings Card That Will Give You Discounts and Track What You Buy..

<p>It doesn’t stop does it?  We all know by now that the savings and rewards cards are trackers and create data on our behaviors that is sold and scored, so here’s another one.  Push folks into high bills for their healthcare, then they need these cards to eat right?  Problem is that not only the food you buy with a discount is recorded but so is everything else, so don’t use this card and buy a candy bar at the same time.  </p> <p>According to this article, you get a card in the mail and they sit back and hope you use it so they can <img title="image" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; margin: 0px; border-left: 0px; display: inline; padding-right: 0px" border="0" alt="image" src="http://lh3.googleusercontent.com/-d526D2PYxj0/VbmjhfOjUXI/AAAAAAABMeM/e06IsYJn9hE/image%25255B2%25255D.png?imgmax=800" width="187" align="right" height="132" />get more data to sell.  </p> <p>If that isn’t enough for you, look at this subsidiary of United Healthcare with their <a href="http://lacrossetribune.com/news/local/lhi-puts-knowledge-on-healthy-eating-menu-with-knourish/article_d6d23a0a-1465-5e7f-8b5c-3ffdaeb03d1f.html">vending machine that does not take cash…</a>here goes the war on cash again.  LHI is a government contractor that is owned by United Healthcare that does a lot of things from giving vets their disability physical and findings and sends it off to the VA to inoculating and performing physicals on soldiers before they are sent out of the country on duty, and that’s a lot of money made there as well. </p> <p><strong>LHI is constantly looking for doctors to work for them at low rates and provide Vets with their VA disability initial information they need to get into the VA system and they are that contractor in 38 states.</strong>   Anyway, with the vending machines, they want to capture more of your credit card data to sell and send off to other behavioral subsidiaries of Untied Healthcare, not to forget that Master Card and Visa love to get the additional transaction data to sell as well if you use one of their cards with the vending machines.  </p> <p><em>“LHI’s fresh food vending pilot program began in March in conjunction with its mother ship, OptumHealth, and Optum’s owner, UnitedHealth Group, in the Twin Cities suburbs. It enlists Optum’s Knourish vending machines to dispense meals designed by an LHI dietitian and chefs at The Waterfront Restaurant and Tavern in La Crosse, where the meals are prepared.”</em></p> <p>So this is yet another profit center for this subsidiary of United Healthcare. <strong> So when you use your credit card in the machine, it’s a couple dollars that go to the overall United Healthcare revenue pool.</strong>  In addition, LHI also campaigns for better mental healthcare so that could possibly be sending more folks over to Optum Mental Health Services, which is home based in the Silicon Valley in California.  </p> <p><strong>If you use the card and decide give out more personal data, you know it’s probably going to one of the many behavioral health subsidiaries of United to be researched and scored.</strong>  That was already started with “scoring” you on medication behavior prediction scores.  Keep in mind that medication adherence prediction scores are not the same as normal monitoring at all, as these are proprietary “scoring” metrics that some data scientist came up with and they are non scientific and you can’t get that score from them at  all, it’s a secret.  Here’s more on that topic…and the war on cash over there.  United Healthcare is one of the biggest sellers of healthcare data.  BD  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/07/patients-who-pay-cash-when-filling.html">Patients Who Pay “Cash” When Filling Prescriptions Are Now Called “Outliers, Pharmacists Required to Fix Outliers as They Show Up As Non Medication Adherence Compliant With 5 Star Systems Full of Flawed Data…</a></h5> <p> <hr />United Healthcare said it is expanding its Healthy Savings program offering discounts on prequalified healthy foods to people in northern Illinois and northwest Indiana enrolled in a United Healthcare insurance plan.</p> <p>Healthy Savings provides potential monthly savings of $150 on prequalified healthy foods from more than 140 food and beverage brands. Plan participants receive a Healthy Savings card by mail and scan their card during checkout at 184 Jewel-Osco, 32 Mariano’s and 45 Shop 'n Save locations throughout Illinois and northwest Indiana. Forty-four Country Market stores will be added in the fall, the company said.</p> <p> <a href="http://supermarketnews.com/health-wellness/united-expands-healthy-savings-program#ixzz3hLIyM46n">http://supermarketnews.com/health-wellness/united-expands-healthy-savings-program#ixzz3hLIyM46n</a></p>

United Healthcare Finds Yet Another Way to Track You At the Grocery Store–Healthy Savings Card That Will Give You Discounts and Track What You Buy..

It doesn’t stop does it?  We all know by now that the savings and rewards cards are trackers and create data on our behaviors that is sold a...

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Anthem and Cigna Merge, What’s In It For Consumers, Nothing Really, But There Will Be a Massive Data Mess of Analytics, Budgets, and You’ll Never Get An Accurate Listing of MDs in Network…

<p>That’s about the size of it as today you have to look at the massive IT sides of business and if you don’t give that some thought, well you might be living under a rock as that’s pretty much what banks and insurance companies are today, huge software companies that manage a lot of money as well as your access to it.  We all know too that regulators have to approve not only this merger but Also the one with Aetna and Humana.  For years insurers have made money making things complex out there as that means profit and I’m not the first and won’t be the last to make that statement.</p> <p>Designing business operations as well as insurance policies has changed.  I wrote a while back about<img title="image" 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" border="0" alt="image" src="http://lh3.googleusercontent.com/-0TZ6_gpU4Is/VbOdvwoCeOI/AAAAAAABMdo/CNbC06J1Ov8/image%25255B3%25255D.png?imgmax=800" width="241" align="right" height="102" /> the large number of “Quants” the insurance business has hired.  You could say these folks are a step above the actuaries as they work with different models and actually at some point they might even be auditing the work of an actuary.  Sometimes a Quant will use the same math model as an actuary as well, even though they may not openly admit it, but it happens.  I started noticing this years ago, especially with United Healthcare as so many of their subsidiaries are not insurance and work around the software, analytics, hearing aids, etc. that they sell, and oh yes, let’s not forget their hospice for profit subsidiary too.  If you don’t know what a Quant is or what they do, scroll on down to the footer and watch video #2, the Quant documentary and it tells about what they do in banking and just relate that to health insurance as what we get are financial models that have been somewhat modified to use in the health insurance business.  </p> <h5><a href="http://ducknetweb.blogspot.com/2014/10/data-scientistsquants-in-health.html"><strong>Data Scientists/Quants in the Health Insurance Business–Modeling Beyond the Speed and Capabilities of Humans To Keep Up With The Affordable Care Act–Turning Into A World of Killer Algorithms That We All Hate..</strong></a></h5> <p>The numbers, of course the real benefits of these mass mergers today as otherwise, they wouldn’t bother as it’s big IT mess and will require spending a lot of money with adding new software, analytics, etc. as well as getting rid of some.  In addition with subsidiary companies, it allows them to sell more of our personal data as well. Health insurers do that, again not right out with the arm that is insuring you, but rather a subsidiary <img title="image" 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" border="0" alt="image" src="http://lh3.googleusercontent.com/-6hS--mUFG9w/VbOdwoIgaPI/AAAAAAABMdw/tAEOCXqaIak/image%25255B7%25255D.png?imgmax=800" width="238" align="right" height="112" />that contains a lot of “scores” about you, and in turn, they buy a lot of this data as well.  A while back I commented about this as I saw this coming for a few years…</p> <h5><a href="http://ducknetweb.blogspot.com/2014/09/health-insurance-business-is-driving.html">Health Insurance Business Is Driving Itself Off a Cliff & Doesn’t Know When to Stop With Collecting, Analyzing and Processing Non Relevant Data With Little Or No Impact On Giving Good Care..</a></h5> <p>We all complain a lot about inaccurate MD “in network” listings, well that will get worse and I do have to somewhat chuckle a bit at the digital illiterates that get up and demand insurers provide accurate listings.  Think about it, don’t you think they would be doing that if they could?  Of course they would be they are buried in lake of data that involve constant change, again thank the Quants that model the profits and tie in stock prices daily, they have their fingers on this pulse all the time and shift the numbers and the models around to keep the profits rolling.  I think even Wall Street is wise to this as the insurance stocks went down on this announcement as well.  Wall Street works the same way with analyzing business models for investing.  In California, doctors can’t even keep up with Anthem on reimbursement policies.  It was less than 90 days from the last update when they rolled out yet another policy change.  Who can keep functioning like this and keep providing good medical care forever?  It’s a big part of the reason doctors are retiring and that the drop out rates in medical school are growing.  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/07/anthem-issues-yet-another-change-to.html">Anthem Issues Yet Another Change to Physician Reimbursement Policies Less Than 90 Days After the Last Change–Here’s A Look at the Other Side of ICD 10 Complexities-Aetna Just Fired Some MDs Over This E/M Services Costing Factor</a></h5> <p>Well maybe by now you could be getting the picture here.  The only benefit that could occur is having a larger group to spread the expense over and when you talk about that, well now you are getting closer to looking at a single payer again.  This has been something I think United Healthcare has been positioning themselves for, if you look at the very close relationship they have had and currently have with HHS and CMS.  Those two agencies have depended for years on United Healthcare “mentored” business models and still do.  Where do you think population health came from?  I saw the beginnings of that years ago with brochures in doctors offices.  Like anything else with analytics, how far will they take it and invade privacy is a big question.  Using registries to get information is a good thing but with all the algorithmic formulas and proprietary code that United runs for profit, you can’t trust everything they put out by all means.  </p> <p>While this is billed to create the largest insurance company,  it’s kind of a joke as United is much larger when you bring in all their entities that are not in the insurance business, everything from a bank to low income housing now and now they want to be in the urgent care business too.  So don’t just look at health insurers as that being their only business, as it’s not and you are fooling yourself if you do.  Actually I think Marylyn Tavenner is the CEO over at the big insurance lobby group right now that United left to further some of the efforts to make this a little bit more fair out there over at HHS and CMS with other insurers having a voice without United controlling everything. </p> <h5><a href="http://ducknetweb.blogspot.com/2015/07/marylyn-tavenner-takes-over-ceo-job-of.html">Marylyn Tavenner Takes Over CEO Job of AHIP, Major Health Insurance Lobby Group in DC And United Healthcare Dropped Out a Few Weeks Ago…</a></h5> <p>So again, what do you as a consumer get out of this merger, pretty much nothing other than having to learn how to click on more websites and study what the new algorithms put out there for you to analyze so you can get some healthcare.  Again there may be the need to spread the cost over a larger group here and of course there’s the subsidies from the government in here too with Obamacare that have an impact.  So again, consumers benefit here?  Not a chance and there will be new algorithms rolled out and more work for you to just get some healthcare when you need it.  </p> <p>Insurance companies are functioning pretty much like bank financial models and there’s a lot of flawed data out there and trickery you could call it as we are seeing this a lot today.  As a consumer you have to be aware of the constant changes and with Quant Modeled polices and business models, they are using tools and analytic way above and beyond the comprehension of the average consumer today, so the financially the battle is rigged, as well as some of the news you read today about such mergers, so be a skeptic when you need to be and try and swim as best you can in the world of “Algorithmic Health Insurance for Profit”…as I can’t think of any other way to describe what’s going on out there.  Check out the videos at the Killer Algorithms page to learn how this works as folks a lot smarter than me have taken time to create some good material that will give you a real good idea on how the math models and algorithms all work today and impact what care you do and don’t get.  BD  </p>

Anthem and Cigna Merge, What’s In It For Consumers, Nothing Really, But There Will Be a Massive Data Mess of Analytics, Budgets, and You’ll Never Get An Accurate Listing of MDs in Network…

That’s about the size of it as today you have to look at the massive IT sides of business and if you don’t give that some thought, well you ...

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United Healthcare Having a Big Bond Sale to Finance Purchase of Catamaran Pharmacy Benefit Management Company, Huge 10.5 Billion

<p>Here we go again, more leveraging and the healthcare we get depends on the financials of such.  Everyone thought the huge Walgreens Bond Sale last year of $8 billion was big, but this over shadows that sale of debt, and of course that’s what this is of course.  In addition, in case you missed it, look at the newly formed subsidiary that raised 36 million from “secret” investors.  We don’t know who the players are there at all.  </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> <p>Also with the Catamaran purchase came a class action lawsuit filed by independent pharmacies.  I can understand that as it’s become a war for everyone’s data and the independents are being squeezed out.  I talked to someone the other day who has friends who work for Catamaran and he said some of the folks are there bracing for layoffs with this deal.  <img title="image" 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" border="0" alt="image" src="http://lh3.googleusercontent.com/-GMLkhej_RW0/VbGTvK9KnMI/AAAAAAABMdQ/1igOHFxSVPs/image%25255B3%25255D.png?imgmax=800" width="243" align="right" height="196" /></p> <h5><a href="http://ducknetweb.blogspot.com/2015/03/united-healthcare-buys-catamaran.html">United Healthcare Buys Catamaran Pharmacy Benefit Manager Just As the PBM Gets Hit With A Class Action Lawsuit For Low Balling Pharmacy Reimbursements..And More Patient Data to Sell and Analyze For Profit</a></h5> <p>So if Cigna and Anthem merge, will Cigna stay with Optum RX/Catamaran?  That could be a good question.  Have you heard about United biggest single shareholder of late with United?  He’s from Brazil and United owns 90% of his big HMO business there.  <a href="http://therealdeal.com/blog/2015/06/09/brazilian-billionaire-is-mystery-buyer-of-53m-one57-pad/">Edson Bueno</a> used a an LLC shell company to buy this very expensive condo in New York at One57.  </p> <p><em>“The tycoon sold a 90 percent stake in his insurance and hospital company to UnitedHealth for $4.9 billion in 2012. Bueno is not the first Brazilian to spend big bucks on New York City real estate.”  Pictures to the right….</em></p> <p>Well this part of what your premiums fund is is not?  So how goes the stock buy backs and dividends now?  Got to have money to pay for those too:)  How leveraged will they get?  BD  </p> <p> <hr />The Minnetonka, Minn.-based health insurance and services company issued <a href="http://www.sec.gov/Archives/edgar/data/731766/000119312515258540/d72098d424b5.htm">$10.5 billion of debt</a>, nearly all of which will cover the cost of buying Catamaran, a pharmacy benefits manager based in Schaumburg, Ill. UnitedHealth said in March it was <a href="http://www.modernhealthcare.com/article/20150330/NEWS/303309973/unitedhealth-to-buy-catamaran-in-12-8-billion-deal">acquiring Catamaran for $12.8 billion</a>. <br />Moody's Investors Service <a href="https://www.moodys.com/research/Moodys-rates-UnitedHealth-Groups-senior-notes-A3-negative-outlook--PR_330430">gave an A3 rating</a> to the debt offering. Fitch Ratings and Standard & Poor's also issued investment-grade ratings to the bonds.</p> <p>The transaction is set to close by the end of this month, UnitedHealth executives said last week during the <a href="http://www.modernhealthcare.com/article/20150716/NEWS/307169981">second-quarter earnings call</a>. UnitedHealth's debt-to-capital ratio increases to 48% with the bond offering, roughly 10 to 20 percentage points above the industry's norm. It plans on reducing that total to 42% by the end of 2016, according to Moody's.</p> <a href="http://www.modernhealthcare.com/article/20150721/NEWS/150729954?utm_campaign=socialflow&utm_source=twitter&utm_medium=social">http://www.modernhealthcare.com/article/20150721/NEWS/150729954?utm_campaign=socialflow&utm_source=twitter&utm_medium=social</a>

United Healthcare Having a Big Bond Sale to Finance Purchase of Catamaran Pharmacy Benefit Management Company, Huge 10.5 Billion

Here we go again, more leveraging and the healthcare we get depends on the financials of such.  Everyone thought the huge Walgreens Bond Sal...

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Marylyn Tavenner Takes Over CEO Job of AHIP, Major Health Insurance Lobby Group in DC And United Healthcare Dropped Out a Few Weeks Ago…

<p>Did you read about 3 weeks ago that United Healthcare bowed out of this group after years of membership?  I think we have a large group of insurers that are in fact flat out tired of United Healthcare monopolizing HHS and CMS with healthcare.  It’s been going on for years and goes back to the the days of when Hillary hired Lois Quam from United and the open door got a little wider.  I’ve wondered in the past<img title="image" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; margin: 0px; border-left: 0px; display: inline; padding-right: 0px" border="0" alt="image" src="http://lh3.googleusercontent.com/-Hjf-pOw3osU/VaiXHVS8F5I/AAAAAAABMc4/FT2J13w_sl8/image%25255B2%25255D.png?imgmax=800" width="170" align="right" height="187" /> why the other insurers have not complained but how do they go up against such a massive conglomerate that’s into everything via hundreds of subsidiaries?  </p> <p>United has “stuff” going on, like wanting to be in the urgent care center business, taking over behavioral or mental health care where ever they can and more.</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> <p>Again I have wondered through the years about how other insurers felt under the massive United impact and huge presence at the CAP, Center for American Progress think tank where you can find other folks like <a href="https://www.americanprogress.org/?s=gruber#!/search=aca&author=11001">Jonathan Gruber</a> and Zeke Emanuel.  </p> <p>We all know how somewhat mild mannered she is and Slavitt probably ran all over her when she was his boss, as how do you supervise an Algo Man who was a one time banker at Goldman Sachs?  </p> <p>I think the other insurers feel that having her name and representation in DC might help shrink the strong hold that United Healthcare and Optum have held over HHS and CMS for years and it’s still happening.  Read the link below from the Daily Kos…do you want a former Goldman Sachs banker Algo Man running Medicare…well that’s what Obama has nominated.  Cuomo of New York took him down a few years ago for his Algo Cheating on paying doctors short on out of network payments and there’s still a bunch of lingering lawsuits over what he did that have not completely settled, and he got a “hall pass” for those while running CMS as the “acting director” now.  </p> <p>He gets scarier every day as well with the White House Fake numbers that come out too.  BD </p> <h5><a href="http://www.dailykos.com/story/2015/07/13/1401710/-Are-You-Up-For-a-One-Time-Goldman-Sachs-Banker-to-Run-Medicare">Are You Up For a One Time Goldman Sachs Banker to Run Medicare?</a></h5>

Marylyn Tavenner Takes Over CEO Job of AHIP, Major Health Insurance Lobby Group in DC And United Healthcare Dropped Out a Few Weeks Ago…

Did you read about 3 weeks ago that United Healthcare bowed out of this group after years of membership?  I think we have a large group of i...

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Patients Who Pay “Cash” When Filling Prescriptions Are Now Called “Outliers, Pharmacists Required to Fix Outliers as They Show Up As Non Medication Adherence Compliant With 5 Star Systems Full of Flawed Data…

<p>I had a conversation with a pharmacist who took some time to cue me in to what’s going on in the world of “Medication Compliance Predictions” and the impact it has on the life and job of a pharmacist.  To tell you the truth, I was absolutely floored at how<img title="image" style="border-left-width: 0px; border-right-width: 0px; background-image: none; border-bottom-width: 0px; float: right; padding-top: 0px; padding-left: 0px; display: inline; padding-right: 0px; border-top-width: 0px" border="0" alt="image" src="http://lh3.googleusercontent.com/-2gQj1nnhPBo/VaiE4ZxQMNI/AAAAAAABMcg/Kw6vqWOa7-g/image%25255B7%25255D.png?imgmax=800" width="248" align="right" height="162" /> much software and algorithms have gone into this process.  If you read my recent post about Express Scripts, you’ll understand.  The metrics that are being used today are over the top and there’s a lot of money being made “scoring” and selling those scores to anyone who has the money and wants the data. </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>That’s right, if you pay cash you are now considered an “Outlier” by the software firms that collect and sell data on prescriptions.  Pharmacists are now seeing patients being given “5 star ratings” on their compliance.  Where does this data come from?  There are many sources available.  First off they can buy your credit card data from MasterCard and any other charge card company and some of these transaction have more than 100-200 fields of data about you available.  We all know about the “reward” programs and how those are gate keepers to mine data and sell it, but it appears now that credit card transactions are also in the picture.  </p> <p><a href="http://www.computertalk.com/feature-stories/cover-story-may-june-2015-patient-engagement-driving-pharmacy-performance">Here’s paragraph from an article</a> that’s more about the pharmacist worrying about their 5 Star rating given to them as employees who are dealing with the 5 Star ratings of the Outlier patient.  One thing to make clear in all of this is the fact that this is not normal monitoring, see if someone has not filled a prescription , etc. this is flawed data that contains metrics that go over the top.  Read this, “find those outlier patients that ruin your numbers”…there’s the wrong with the focus.  You may be doing fine taking your medication but the metrics are not being hit, again, the data is flawed.  </p> <p><em>“For example, Michelle Farrell has begun looking at the medication possession ratio data report in her QS/1 system and looking to tie that back to her star ratings. Brent Dunlap looks at the EQuIPP dashboard to gain insight into outlier patients who are causing their numbers to dip and who may have health issues they can help with. And Brian Beach runs a report out of Kelley-Ross’s PioneerRx system when something doesn’t look right in EQuIPP. “We’ll use our ability to drill down into our data to look at an adherence metric like proportion of days covered, for example,” says Beach. “We see which patients we are not hitting our benchmarks with, and then we’ll reach out to the patient or the provider to try to resolve any issues.” For Beach, this is all about providing value by showing that the pharmacy is being proactive in its interventions that benefit patients, and can even help prescribers meet benchmarks, too.”</em></p> <p>The pharmacist went on to tell me that people who pay cash all the time get “one star” and they have to go through this process to talk about why they only have one star.  This is one more way to work on the war on cash with making patient “outliers” who use cash.  So what’s really wrong with this system?  Why are patients being called “outliers” until they can prove their innocence?  That’s exactly what we having going on here.  Again this not normal medication compliance monitoring, it’s all about getting the pharmacists up to a higher score by going after bogus rated “Outliers” that the software creates.  It’s the methodologies used and the context.  So good luck getting “patient engagement” here with using the data to find “the bad guys” if you will.  </p> <p>All those who pay cash are given the “non compliance” ding which is not fair, only because their <img title="image" style="border-left-width: 0px; border-right-width: 0px; background-image: none; border-bottom-width: 0px; float: right; padding-top: 0px; padding-left: 0px; display: inline; padding-right: 0px; border-top-width: 0px" border="0" alt="image" src="http://lh3.googleusercontent.com/-KDDBEc3i-I4/VaiE5CvPnTI/AAAAAAABMco/U9a02nrysU8/image%25255B3%25255D.png?imgmax=800" width="392" align="right" height="189" />data can’t track everything.  Again we are not disputing monitoring those with chronic conditions to see if they are filling their prescriptions here as the issue as that’s pretty normal anymore to take a quick look and see but rather the “scoring” of those at a one star level who pay cash.  </p> <p>The sad reality here is that it’s all about “stars” when you review all the material and not about medication compliance as the way the model is written.  Most pharmacists I know reach out and help patients with or without stars.  I’m sure patients love being scored with one star if they can’t track the payment cycle of their prescription.  How do you engage with this?  You don’t as it falls into “excess scoring” of both patients and pharmacists, same battle doctors have had for years and only the data sellers get rich. Education is still a much better route without having to make billions selling patient prescription data.  These scores, outlier or not, get sold to insurance companies.  </p> <p>In many pharmacies the pharmacists can’t consult with you face to face until they are certified and have taken this <a href="http://www.outcomesmtm.com/pharmacy-overview.aspx">Outcomes MTM certification course,</a> which of course costs money.  Nope, they are not qualified on their own to talk to you the patient face to face on their own anymore, they need to be certified to do that and this company is making money.  CVS is a big user of the Equipp program so you can be assured they have a lot of “Outlier” patients with only one star:)  Be ready for the pharmacist push to be more prevalent as the pharmacists “have” to make those numbers.  If you paid cash at Walgreens for your last prescription, you’re screwed on this 5 star rating.  If they bring you all in house using credit cards, CVS has a lot more data to mine and apps to create to even get more of your data:)  So with your future visits to CVS if you pay cash, be aware that you will become one of their “Outliers”.  BD  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/04/cvs-to-share-more-medication-adherence.html">CVS to Share More Medication Adherence Love With New Contracts–Will Have More Data to Sell…</a></h5>

Patients Who Pay “Cash” When Filling Prescriptions Are Now Called “Outliers, Pharmacists Required to Fix Outliers as They Show Up As Non Medication Adherence Compliant With 5 Star Systems Full of Flawed Data…

I had a conversation with a pharmacist who took some time to cue me in to what’s going on in the world of “Medication Compliance Predictions...

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Anthem Issues Yet Another Change to Physician Reimbursement Policies Less Than 90 Days After the Last Change–Here’s A Look at the Other Side of ICD 10 Complexities-Aetna Just Fired Some MDs Over This E/M Services Costing Factor

<p>I guess the question is anymore is “how bad do you want to be a doctor”.  The red tape and what insurers and CMS are calling for is not improving care very much at all but rather it’s serving to increase the profits of a lot of Health IT vendors, in this case it’s McKesson with<img title="image" 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" border="0" alt="image" src="http://lh3.googleusercontent.com/-7nBQsTZUbP0/VZa620DNsaI/AAAAAAABMcA/cdnt9uGgiYs/image%25255B3%25255D.png?imgmax=800" width="318" align="right" height="233" /> their systems they use.  Just a couple days ago we had this to where Covered California insured participants are getting screwed on privacy with no opt out on being “scored” again and all these so called “scores” which eventually end up denying care or money are going to CMS.  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/06/covered-california-insurance.html">Covered California Insurance Participants to be Risk Assessed With Individual Scores To Be Sent to CMS By Anthem–Appears To Be No Opt Out For Privacy, Payback Time For the ACA Subsidies As Feds Get Your Scored Data</a></h5> <p>It’s no mystery anymore that when insurers change reimbursement procedures, it’s about a 99% chance these policies will end up paying doctors less.  It’s been going on for years and was first made popular by Ingenix, the subsidiary of Untied Healthcare which is now called Optum Insights.  They figures out how to use algorithmic formulas years ago and make things more complex and increase their profits.  Everyone else is following suit.  Don’t forget the former CEO of Ingenix is running Medicare now, so be afraid be very afraid of the one time Goldman Sachs Algo Man as that’s all he’s done, is use algorithms to increase profits and I assume he’s going to do the same to bring in more money for CMS.  </p> <p>It’s getting to the point that coding a doctor’s visit is like doing income taxes with every patient visit.  Sure there’s automated solutions but how much of a cut do the algorithms take to give a doctor that capability, quite a bit.  That’s how Health IT software works, build one layer, add another and another with new queries and bingo more money goes to IT and less for actual compensation of doctors taking care of patients.  HHS is just as bad with being mentored for years by United Healthcare with building their models and now they are kind of stuck a bit as the models are not working anymore.  </p> <p>That’s common and happens every day in the business world and CMS can’t quite figure it out it seems, but we have the six degrees of Bob Rubin running HHS and all we seem to get are a lot of selfies and templated boring stats that say the same thing over and over. It’s the worst and most lost leadership I’ve ever seen as the complexities are eating them up.  They make mistakes too in some of their perceptions, like this with medical records and “Information Blocking” which has kind of been the laughing stock of those in Health IT for a while now as we all know EMR vendors don’t have time to write code to do such a thing.  Now they are trying to save face for another incident of “Perception-Deception” that occurred or as I have called it for a few years, “The Sebelius Syndrome” in being Algo Duped and looking for Algo Fairies.  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/05/information-blocking-finally-revealed.html">“Information Blocking” Finally Revealed for the Hoax and Make Believe Story That It Is With Medical Records Sharing and Interoperating…</a></h5> <p>First thing doctors say when new rules come out from insurers or CMS, where are they cutting our pay?  Duh?  Each insurer also has their own coding rules, so here comes United, aka Optum 360 to make money off it it too with taking over revenue cycling.  They love it, the more complex it gets, the more billing algorithms they can build and decipher.  Anyone see the a system to this?  So look, hospitals getting hit with this change and others, well Optum 360 comes in with algorithms to work the algorithms…Optum 360 just loves seeing stuff like this happening as they get to bring their algorithms in and hospitals get to even pay more.  They just layer on their algorithms on top of McKesson.  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/04/mayo-clinic-is-latest-to-outsource.html">Mayo Clinic is the Latest to Outsource Revenue Cycling to Optum 360, A United Healthcare/Dignity Health Company Pursuing Hospital Contracts All Over the US For Profit…</a></h5> <p><strong>Health insurance world is just about operating just like markets anymore, it’s all about the algos to make money, not about your healthcare.</strong>  Those doctors who are not in algorithmic compliance, well they get fired by another set of algorithms…so again who wants to be a doctor anymore?<strong><u>  The government and insurers are running them off faster than enough can graduate and enter the world of healthcare.  BD  </u></strong></p> <p> <hr />Anthem Blue Cross <a href="http://www.cmanet.org/files/assets/news/2015/06/claims-edit-update-provider-notice-letter-june-2015-2.pdf">recently notified</a> physicians of additional upcoming changes to its reimbursement policies and claims editing software, ClaimsXten. The additional changes, scheduled to go into effect on September 14, 2015, come less than 90 days after Anthem’s most recent set of <a href="http://www.cmanet.org/news/detail?article=anthem-blue-cross-announces-changes-to1">changes</a> were implemented in July, and less than a month prior to the implementation of ICD-10. </p> <p>Anthem states that the additional changes are necessary to bring its claims editing system in line with correct coding guidelines.</p> <p>Anthem did not provide a detailed listing of all the incorporated changes; rather, it provided a reference sheet showing examples of the types of edits that will be incorporated as part of its September update. Concerned that the lack of detail could lead to confusion for physician practices on one policy change, the California Medical Association (CMA) asked Anthem for clarity on the Inpatient Evaluation and Management (E/M) services example. Specifically, the first example states, “Inpatient Evaluation and Management services (i.e., inpatient admission, observation services, and consultation services) should be billed only once by the same provider during an inpatient stay.” CMA asked Anthem to clarify whether the scope of the change is limited to the three services listed or whether it includes other inpatient E/M services.</p> <p>Physicians can also access this information via the <a href="https://provider2.anthem.com/wps/portal/ebpmybcc">Blue Cross ProviderAccess website</a> (log in, then select “Reimbursement Policies and McKesson ClaimsXten Rules” under the “What’s New” section).</p> <p><a href="http://www.cmanet.org/news/detail/?article=anthem-blue-cross-announces-further-changes-to">http://www.cmanet.org/news/detail/?article=anthem-blue-cross-announces-further-changes-to</a></p>

Anthem Issues Yet Another Change to Physician Reimbursement Policies Less Than 90 Days After the Last Change–Here’s A Look at the Other Side of ICD 10 Complexities-Aetna Just Fired Some MDs Over This E/M Services Costing Factor

I guess the question is anymore is “how bad do you want to be a doctor”.  The red tape and what insurers and CMS are calling for is not impr...

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Aetna Ends Up Buying Humana for $37 Billion-More Medicare Advantage Plans Under One Roof, Stock Buy Backs And the Never Ending Puzzle of Healthcare Profits by the Algorithm….

<p>So we are all watching to see how insurance merger mania goes and here’s the next after Centene bought Health Net a couple days ago.  In the Medicare Advantage market Aetna is the distant third behind United and Humana so with purchasing the #2 Medicare Advantage insurer this moves Aetna into the #2 spot.  According to what has been published so far, there won’t be any changes yet as far as operations and<img title="image" 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" border="0" alt="image" src="http://lh3.googleusercontent.com/-k6swCJqe7Sc/VZau_G2qnLI/AAAAAAABMbQ/JTK88uygVas/image%25255B3%25255D.png?imgmax=800" width="280" align="right" height="87" /> Humana will operate as they have.  We know down the road this will change but for now it seems to be like a subsidiary.  United has been clawing up the back side of Humana on contracts as well with pricing themselves cheaper.</p> <h5><a href="http://ducknetweb.blogspot.com/2014/09/humana-loses-major-contract-in.html">Humana Loses Major Contract in Wisconsin to the “Too Big To Fail Insurer, United”</a></h5> <p>What we all wonder about though is the CMS payback that Medicare has said they want back, around $70 Billion in fraud that insurers bilked the agency for by using risk fiddling formulas.  I assume this might be one of the reasons that consolidation of company functions might be down the road a bit.  This move takes Humana out of the vulnerable spot light at least for now as Aetna owns the insurance licenses the company has.  Earlier I had written about the value of the licenses with health insurers and the Medicare proposed collection of the Medicare fraud money.  </p> <h5><a href="http://ducknetweb.blogspot.com/2015/06/with-humana-up-for-sale-whats-impact-of.html">With Humana Up For Sale, What’s the Impact of the Medicare Risk Assessment Re-Run for Said Medicare Fraud? It’s a Big Potential Monetary Exposure For Humana and Other Insurers…</a></h5> <p>Aetna was also reported firing more doctors in California this week with not meeting their “standards” so again <img title="image" 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" border="0" alt="image" src="http://lh3.googleusercontent.com/-xl-qJ9KqV5I/VZau_2oNBYI/AAAAAAABMbY/HDaczH1KW2s/image%25255B15%25255D.png?imgmax=800" width="270" align="right" height="107" />as well as with United we have a lot of Secret Scoring of Doctors going on here.  It’s actually gone on in California for a while as I have had conversations with doctors who have been dropped by Aetna and actually a couple of them said “what a relief” to not have to be bound to all those performance algorithms as usually one really sick patient puts them out of the “algorithm” quality game anyway and there’s nothing they can do when such occurs.  So that’s a little bit about how doctors get fired, one sick patient and they can’t fiddle the numbers enough to Aetna’s satisfaction, they’re out as well as the big mess of red tape the doctors have to deal with to be in network.  United does the same thing and has fired quite a few doctors in California.  Both Aetna and United both bailed out of the individual policy programs in California last year and probably for good reason as the networks were so limited, it was very hard to find doctors within those networks.  </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>Humana still hold the south Tri-Care Contract and I think that comes up for bid again either later this year or next year as they run for 5 years so Aetna will get that with the purchase as well.  When the contracts for Tri-Care come up, well who’s going to be left to bid could be an interesting question.  Both insurers also have some healthy stock buy back programs going as well and you pay for those with your premiums.  </p> <p>The board of directors directors will include 4 from Humana and will grow in size as well.  These are very complicated mergers as well.  Insurers have just absolutely buried themselves with data complexities, some of which is pretty useless but they have to decide what to do with their masses of burial grounds of data that basically do nothing today and of course the insured pay for all of that.  </p> <h5><a href="http://ducknetweb.blogspot.com/2014/09/health-insurance-business-is-driving.html">Health Insurance Business Is Driving Itself Off a Cliff & Doesn’t Know When to Stop With Collecting, Analyzing and Processing Non Relevant Data With Little Or No Impact On Giving Good Care..</a></h5> <p>In addition you have the data selling subsidiaries of Humana and Aetna to consider as well and their work with pharma companies to analyze and market consumers.  You can’t always believe 100% that insurers are just getting stuck on high drug prices to pay, they work and sell data together as well.  <strong>We all grew real tired too of all the failed Aetna apps that they thought would just jump out there and change people’s behaviors to what “they” want for profit too:)</strong> </p> <h5><a href="http://ducknetweb.blogspot.com/2013/08/pharma-and-health-insurance-companies.html">Pharma and Health Insurance Companies Pairing Up, Humana’s Analytics Subsidiary and Lilly To Figure Out How to Save (Make) Money and Provide Better Patient Care–Selling Research Data That Competes With FDA Sentinel Initiative</a></h5> <p>Humana has also fiddled around a little in the EMR business offering discounts to doctors who buy Greenway systems.</p> <h5><a href="http://ducknetweb.blogspot.com/2013/08/humana-offers-financial-incentives-for.html">Humana Offers Financial Incentives for Primary Care Physicians To Use Greenway EHR PrimeSUITE–Up to 85% Reimbursement Possible</a></h5> <p>Humana also made the news with possible trading violations as well. </p> <h5><a href="http://ducknetweb.blogspot.com/2013/04/humana-fires-its-lobbying-firm-over.html">Humana Fires It’s Lobbying Firm Over Possible Insider Trading Violation</a></h5> <p><strong>Aetna ended up stalling off their Ingenix overcharge payments to doctors long enough to where a lack <img title="image" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; margin: 0px; border-left: 0px; display: inline; padding-right: 0px" border="0" alt="image" src="http://lh3.googleusercontent.com/-nN4cRMik8zM/VZavA1Z8ocI/AAAAAAABMbg/9NuiX1QwqWY/image%25255B22%25255D.png?imgmax=800" width="187" align="right" height="81" />of interest loophole kept them from having to pay doctors for the 15 years of Ingenix (United Healthcare) bad algorithm use to gain bigger profits.</strong>  Here’s the original settlement that was announced and Aetna never paid at the links below.  In addition, remember who’s running Medicare today?  It’s the former CEO of Ingenix, Andy Slavitt who created all these algorithms and formulas that allowed insurers to collect unprecedented amounts of money that was flawed but yielded bigger profits for insurers.  Interesting as Aetna never paid this but took a write off for it.  Couple back links below on the history of this.  </p> <h5><a href="http://ducknetweb.blogspot.com/2013/01/aetna-payment-of-120-million-to-settle.html">Aetna Payment of $120 Million To Settle 15 Year Ingenix/United HealthCare Out of Network Erroneous Payment Algorithms Cuts Income for 4th Quarter</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2012/12/one-more-court-case-settles-for-120.html">One More Court Case Settles for $120 Million With Aetna For Around To 13 to 15 Years of Short Paying Doctors Using Defunct United Healthcare (Ingenix) Data Base for Out of Network Reimbursements</a></h5> <p>Humana also owns some doctors groups like this one they bought a few years ago.  United Healthcare is the king of that though as they own tons of doctors groups under the “Optum” subsidiary.  That gets real interesting too as in some areas you have Optum managing Humana insurance plans, so a subsidiary and a large one of United manages other insurance plans.  So there’s more than just insurance groups in this buyout for sure, so don’t lose sight of that with subsidiaries where all the action takes place half the time.  </p> <h5><a href="http://ducknetweb.blogspot.com/2011/09/humana-to-acquire-md-care-hmo-in.html">Humana to Acquire MD Care HMO in Southern California–HMO/IPA Purchases Continue With Insurers</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2010/12/humana-acquires-concentra-inc-privately.html">Humana Acquires Concentra Inc.- A Privately Held Healthcare Company in Texas</a></h5> <p>There were also all kinds of interesting marketing plans that have taken place over the years too, look at this one for example. </p> <h5><a href="http://ducknetweb.blogspot.com/2010/04/humana-and-cigna-partnering-to-sell.html">Humana and Cigna Partnering to Sell Medicare Humana Advantage Plans To Employers In Cigna’s Data Base</a></h5> <p>Aetna has had their news worthy issues as well…this first one is kind of a big one.</p> <h5><a href="http://ducknetweb.blogspot.com/2013/12/aetna-gets-hit-with-federal-lawsuit.html">Aetna Gets Hit With Federal Lawsuit Accusing CEO and Board of Directors Of Providing False And Misleading Information To Shareholders–SEC Violation</a></h5> <p>When United has fired doctors, in some areas Aetna has come in and picked them up.  Think there’s any chance<img title="image" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; margin: 0px; border-left: 0px; display: inline; padding-right: 0px" border="0" alt="image" src="http://lh3.googleusercontent.com/-Ae65wKyeWDU/VZavCB1UF_I/AAAAAAABMbo/EJpdEYi21kk/image%25255B19%25255D.png?imgmax=800" width="268" align="right" height="102" /> of getting a somewhat accurate listing of doctors out there any more with insurers?  Good luck as those in Congress and otherwise like us are just frustrated to no end and as long as most of areas of insurance are run by cost algorithms rather than a care focus, this problem will not go away but rather get worse with trying to figure out who’s in network any more.  <strong>Again you just have to laugh at these so called “experts” with no data mechanics logic demanding that insurers do a better job with listing doctors in networks as the insurers themselves are victims of their own complexities they built and the “experts” seem to be too dumb to see it and keep demanding change.  Those experts are looking for some Algo Fairies indeed, what I call frequently refer to as the “Sebelius Syndrome”.  </strong></p> <h5><a href="http://ducknetweb.blogspot.com/2013/10/united-healthcare-drops-300-southwest.html">United Healthcare Drops 300 Southwest Florida Doctors While Aetna Announces It Is Expanding Medicare Advantage Doctor Networks With Employer Sponsored Medicare Advantage Plans, No Word Yet On Individual Polices–Clustered Algorithm Analytics Creating “Black Box” Risk Assessments</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2012/09/arent-these-health-insurance-contracts.html">Aren’t These Health Insurance Contracts a Bitch!Aetna Suing City of Jacksonville Over Decision to Award Contract to Florida Blue- Battle of the Algorithms</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2012/04/aetna-notifies-130-texas-doctors-that.html">Aetna Notifies 130 Texas Doctors That It Will Terminate Their Contracts on July 1 – E & M Codes Primary Levels 4 and 5 Billing Analytics For Peer Comparison Used To Substantiate the Decision - Video</a></h5> <p>When it comes to medical operating loss, one might wonder if Aetna will let Humana in on their Cayman Islands re-insurance program too.  Read that one if you want to see some real complexities and questionable backers, bonds in the Caymans.  I know just what you want to read about when all you want to do is get a little healthcare but this is the world the US government allowed to grow to where we have to finance stock buy backs with premium payments as well in order to just go to the doctor or hospital.  </p> <h5><a href="http://ducknetweb.blogspot.com/2014/01/aetna-completes-200-million-dollar.html">Aetna Completes $200 Million Dollar Cayman Island Re-Insurance Multi Year Protection Bond Deal</a></h5> <p>Ok so what’s next?  I’ve said a few times that Aetna is a mini United as they have seemed to emulate of what United has done with healthcare by the algorithms.  When you write about this stuff for years, patterns are pretty easy to spot.<strong>  So the big <img title="image" 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" border="0" alt="image" src="http://lh3.googleusercontent.com/-_Iwtgo3P3ok/VZavCzPzatI/AAAAAAABMbw/UUJ5H1uIKqs/image%25255B26%25255D.png?imgmax=800" width="374" align="right" height="262" />question now is United I suppose with coming in as a bigger fish here and again the question of why is a former United Healthcare Executive and one time Goldman Sachs banker running Medicare?  There’s way too much power in that spot with even just timing the $70 billion dollar fraud money back program.</strong>  </p> <p>When you think of it that way, these Medicare Advantage insurers have a lot to loose there with some revenue, so with this fraud cloud of $70 billion hanging there, why are these companies so over valued at times?  Good question to think about maybe.  Here’s the future sadly with pushing more expense to the insured individual and less coverage and Handy Andy <strong>(Andy Slavitt, head of Medicare) who did that for years with under paying doctors with Ingenix is in the driver’s seat to do that at Medicare.  </strong>It is what he did for years and was sued all over the place for it with cheating algorithms of Ingenix, so bad to the point they had to change the name to Optum Insights as way too many were bit by the false positives those algorithms created.   BD  </p> <h5><a href="http://ducknetweb.blogspot.com/2014/08/cms-discovers-that-insurers-offering.html">CMS Discovers That Insurers Offering Medicare Advantage “Really Know How To sharp Shoot A Model With Adjusting Risk For Profit”, A Common Everyday Occurrence in Financial Markets…</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2014/09/seniors-facing-some-sharp-medicare.html">Seniors Facing Some sharp Medicare Advantage Premium Increases And Many Plans are Being Dropped As CMS Gets Their Next Dose of Said Algorithmic Fraud To Sort Out With the Risk Fiddlers…</a></h5> <p>Stay tuned for the next chapter of the complex World of Algorithmic Mergers and Acquisitions of Health insurers…BD</p> <p> <hr />Insurance giant Aetna Inc. <a href="https://fortune.com/company/AET">AET</a> -2.63% </a>is to buy Humana Inc. <a href="https://fortune.com/company/HUM">HUM</a> -2.87% </a>for $37 billion, in a deal that will create the second-largest managed care company in the U.S. behind UnitedHealth Group <a href="https://fortune.com/company/UNH">UNH</a> -1.27% </a>.</p> <p>The deal is the first in an expected wave of consolidation across the sector as health insurance companies look for ways to bulk up and reduce costs to stay competitive in the post-Obamacare world. It will transform Aetna, which has traditionally focused on employers’ health care plans rather than individuals’.</p> <p>Aetna has had to pay a relatively steep premium to get its hands on Humana: the offer is nearly 30% above where Humana’s shares were trading in May, before news of a possible sale leaked. The prize is a base of 3.2 million Medicare Advantage-enrolled customers that will more than triple its existing Medicare membership.</p> <p><a href="https://fortune.com/2015/07/03/aetna-to-buy-humana-for-37-billion/">https://fortune.com/2015/07/03/aetna-to-buy-humana-for-37-billion/</a></p>

Aetna Ends Up Buying Humana for $37 Billion-More Medicare Advantage Plans Under One Roof, Stock Buy Backs And the Never Ending Puzzle of Healthcare Profits by the Algorithm….

So we are all watching to see how insurance merger mania goes and here’s the next after Centene bought Health Net a couple days ago.  In the...

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Theranos Gets First FDA Approval for “Drop of Blood Test” for Herpes

<p><a href="https://www.theranos.com/">Theranos</a> has stated they plan to get everyone of their tests approved by the FDA in time and it appears this the first.  The cost for the test is $9.07 so anyone insured or not insured can pretty much get the test done.  In Arizona, people don’t require a<img title="image" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: right; padding-top: 0px; padding-left: 0px; margin: 0px; border-left: 0px; display: inline; padding-right: 0px" border="0" alt="image" src="http://lh3.googleusercontent.com/-QNU51m3_B34/VZYPBIB5y-I/AAAAAAABMa8/1689ZXsXA04/image%25255B2%25255D.png?imgmax=800" width="149" align="right" height="187" /> doctor to prescribe the test either.  I don’t know if this test was singled out to be first or not, but it’s not a bad start.</p> <p>So far most know the company through their Wellness Centers in Walgreens stores but now they are expanding into doctor’s offices and in to hospitals.  I said a long time ago it was not a bad idea for doctors on their own to get set up with the mail order service.  The prices are certainly right and they can mean the difference of one getting a test or not.  The company is not required to get FDA approval on their tests but it’s rather a commitment from the company to do so. </p> <p>Having other choices in addition to going to a Walgreens store is also a good thing.  </p> <h5><a href="http://ducknetweb.blogspot.com/2014/11/its-basic-human-right-for-individuals.html">“It’s A Basic Human Right for Individuals to Have Access-One Drop of Blood”Theranos CEO & Founder, Elizabeth Holmes TED Video</a></h5> <h5><a href="http://ducknetweb.blogspot.com/2014/06/theranos-on-road-to-expansion-and.html">Theranos On The Road To Expansion and Growth - Changing the Face of Medical Lab Tests, One Small Drop of Blood</a></h5> <p>This company is doing good things in the world of medicine today, they are functioning in the real world which what we need.  I think we are all burned out on all the “virtual” apps and other items that come and go with a short life in healthcare.  This one is here to stay. BD  </p> <p> <hr /></p> <p>SAN FRANCISCO — In a ringing endorsement of its technology and a counter to its critics, Silicon Valley bio-tech company Theranos announced Thursday that its proprietary blood-testing system has received clearance from the Food and Drug Administration.</p> <p>The FDA has granted approval to Theranos' finger-stick method and, more specifically, for its testing of the herpes simplex 1 virus.</p> <p>"In order to realize our vision of early detection, lab tests must meet the highest quality standards, standards that are comprehensively set by FDA," founder Elizabeth Holmes said in a statement.</p> <p>"FDA review is a uniquely rigorous process we undertook voluntarily because we remain deeply committed to ensuring that our systems and all of our laboratory developed tests are of the highest quality, and that patients and their physicians have access to the most accurate information about their health."</p> <p><a href="http://www.usatoday.com/tech/">http://www.usatoday.com/tech/</a></p>

Theranos Gets First FDA Approval for “Drop of Blood Test” for Herpes

Theranos has stated they plan to get everyone of their tests approved by the FDA in time and it appears this the first.  The cost for the t...

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Health Net Gets Sold-Centene Managed Care Is the Buyer-Conglomerate of Companies Involved in Medicaid, Medicare and Other Care Managing Business Units

<p>Centene is yet another managed care organization which you could say was a competitor of Health Net in some ways.  The big pull here is becoming one of the largest if not the largest company managing Medicaid.  Both boards have approved the merger/acquisition but as I understand share holders still need to turn in their vote. </p> <p>Adding in Health Net’s Medicare business give Centene many more opportunities to bid on Tri-Care and other<img title="image" 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" border="0" alt="image" src="http://lh3.googleusercontent.com/-K7dnU8x2nm4/VZYIVvcwpbI/AAAAAAABMak/ONgD9BZT-b4/image%25255B8%25255D.png?imgmax=800" width="220" align="right" height="86" /> such managed care contracts.  If you look at the image below you can get a better idea of the companies that belong to the conglomerate.  US Script is yet another pharmacy benefit manager.  You may want to read this link below and see what’s going on there as many but not all PBMs are diving out over their heads with “predictive” medication adherence which is different than normal medication compliance programs. </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>Optum is a big player in Medicaid contracts in California and this will be competition for them in this area.  Centene is assuming $500 million in debt with the deal.  In July 2009, UnitedHealth Group bought Health Net's northeastern licensed subsidiaries for $450 million and anyone in the northeast with a Health Net policy is under written by United as Health Net just managed some of it after the acquisition of the licenses.  </p> <h5><a href="http://ducknetweb.blogspot.com/2009/07/unitedhealthcare-buys-portion-of-health.html">UnitedHealthCare Buys a Portion of Health Net in the Northeast</a></h5> <p>Health Net sold its Medicare Prescription Drug Plan business to a subsidiary of CVS Caremark for approximately $160 million in cash in the year 2012.  Health Net still holds the Tri-Care northeast contract for military care.  Humana has the south and United has the west coast contract after they sued the DOD to get it.</p> <h5><a href="http://ducknetweb.blogspot.com/2009/07/health-net-and-humana-file-protests.html">Health Net and Humana File Protests over Military Healthcare Awards to UnitedHealthcare and Aetna</a></h5> <p>As a little side note, Health Net got in trouble with the Ingenix data base as well and had to change their billing a while back.  The former CEO of Ingenix who everyone sued is now running Medicare…not a good thing.</p> <h5><a href="http://ducknetweb.blogspot.com/2009/06/health-net-agrees-to-stop-using-ingenix.html">Health Net Agrees to Stop Using Ingenix Database for Calculating Reasonable and Customary Fees</a></h5> <p>This was an interesting acquisition and some of the news said United could counter offer but I seem to think not as the price is too high for them right now.  BD</p> <p> <hr />NEW YORK – Centene Corp. agreed to buy Health Net for about $6.3 billion in cash and stock, creating a combination of two smaller U.S. health insurers ahead of an expected round of mergers among the industry’s giants.</p> <p><img title="image" style="border-top: 0px; border-right: 0px; background-image: none; border-bottom: 0px; float: left; padding-top: 0px; padding-left: 0px; border-left: 0px; display: inline; padding-right: 0px" border="0" alt="image" src="http://lh3.googleusercontent.com/-4GzkqEvN02Y/VZYIWawlUCI/AAAAAAABMas/DLE1YSOQDTU/image%25255B4%25255D.png?imgmax=800" width="494" align="left" height="325" /></p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p> </p> <p>Health Net investors will get 0.622 shares of Centene and $28.25 in cash for each share they hold, the companies said in a statement on Thursday. The implied price of $78.57 a share is 21 percent more than Health Net’s closing stock price Wednesday.</p> <p>The deal gives Centene the biggest market share among private administrators of Medicaid, the federally funded health program for the poor — a bet that the U.S. government will keep playing a larger role in health care. The transaction would give Centene a bigger presence in the California Medicaid program, which is the largest in the U.S. with more than 12 million individuals, and provides an entry into the Medicare market.</p> <p><a href="http://www.startribune.com/centene-to-buy-health-net-for-6-3b/311520561/">http://www.startribune.com/centene-to-buy-health-net-for-6-3b/311520561/</a></p>

Health Net Gets Sold-Centene Managed Care Is the Buyer-Conglomerate of Companies Involved in Medicaid, Medicare and Other Care Managing Business Units

Centene is yet another managed care organization which you could say was a competitor of Health Net in some ways.  The big pull here is beco...

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