Category: Hospitals

Why is UnitedHealth rebating insurance premiums?

published date
May 11th, 2020 by
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Tell me something good!

It’s no surprise why auto insurers like State Farm and Geico are sending rebates to customers this spring and summer. No one’s driving, so accident claims are way down and insurers are paying out very little. No one expects drivers to make up for lost time by crashing their cars more often once they return to the roads. That means a dollar saved now on claims is a dollar saved forever. Insurance companies and state insurance commissioners realize this, too and that’s why the rebates are coming.

But you might be surprised that health insurers, starting with UnitedHealth are beginning to do the same thing. United is offering a 5 to 20 percent credit on June billing statements, which is the same order of magnitude as the auto insurers.

So the questions are:

  1. Aren’t insurers spending a fortune on the surge of COVID-19 patients as they overwhelm the medical system?
  2. What about the coming surge of deferred elective surgeries and the ‘train wrecks’ with acute or chronic conditions that have stayed away from the emergency room and doctor’s office? Won’t insurers need the money to pay for those when they return?

And the answers?

Insurers are spending a lot on some COVID-19 patients. Big bills are rolling in for hospitalized patients, especially those that land in the ICU and are on ventilators for weeks. But even though a lot of people are sick, it’s only the hospitalized patients that incur expenses. With no costly outpatient or drug treatments, overall COVID-19 costs are not so high. Also, many of these patients are older (Medicare) or poorer (Medicaid), not in United’s commercial markets, where the rebates are focused.

Other than COVID-19, the medical system is eerily quiet. Essentially the only other bills are for telemedicine, some cancer treatments, and medications for chronic illness.

We do hear about a coming ‘second wave’ of non-COVID-19 patients later this year as hospitals reschedule elective surgeries, people who have been avoiding the emergency room come back in worse shape, and chronic care patients incur more intensive treatments after declining.

These assumptions are driven by a combination of what seems like common sense, clinician desires to help patients, and wishful thinking by hospital financial chiefs.

But UnitedHealth knows something that others don’t: utilization and costs are not going to rise as fast as people assume. So insurers are getting out ahead of it before regulators, the ACA medical loss ratio requirements, and public opinion force their hand.

Here are some thoughts I shared a week ago.

After the surge: Hospitals prep to bring back regular patients while virus cases linger describes how hospitals are gearing up to work through the backlog of canceled appointments and procedures. Hospitals assume that there will be tremendous, pent up demand for their services. They are looking forward to getting back to normal with cases that pay the bills.

 They will be in for a rude surprise, however, because many people will continue to stay away. Instead patients will use telemedicine, pursue less aggressive treatments, or just wait for time to heal what ails them. For years, healthcare experts and insurers have known that hospital care is over-utilized and sometimes dangerous. Now  COVID-19 has done what co-pays, deductibles and hospital safety reports never could –keep patients away.

 It’s no surprise that elective procedures and routine visits have plummeted. After all, hospitals canceled them. Surprisingly, the use of emergency rooms in Boston for strokes, heart attacks and appendicitis has also dropped by half during the emergency.  Many emergency patients will return, but those with common issues like back pain and rashes will think twice or three times before coming in. Patients who are due for colonoscopies or mammograms will put them off even longer than usual.


By healthcare business consultant David E. Williams, president of Health Business Group.

Where did all the emergencies go?

published date
April 30th, 2020 by
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Do you need me?

When COVID-19 hit, hospitals knew they would see a decline in elective surgeries and routine visits. After all, they canceled them! But the volume of patients visiting the emergency room has also dropped dramatically, and no one can seem to fully explain it. Sure, maybe we could expect fewer car crashes and skiing injuries. But heart attacks and strokes? If anything it seems like those numbers should be going up due to higher stress levels. Yet, the analyses in cardiac care during the pandemic show a sharp decline not only in elective cardiac procedures, but also in cardiac catheterizations for acute heart attacks, specifically, those with ST segment elevations – the most life threatening type.  

Conventional wisdom tells us that the drop in ER visits is a bad thing. Patients must be dying at home, outcomes must be worsening, and the patients that do survive will show up as train wrecks once the pandemic subsides. Those assumptions are probably true to a certain extent, but the open question is how true?   Acute conditions and complications warrant acute care.  But in the routine care of behavioral health and other chronic conditions such as diabetes and hypertension, extensive overuse of the emergency room rather than other ambulatory settings has been a prime area of concern and debate for several years.  

We know that ERs are overused in normal times. And we think they’re underused now during the pandemic, but to what extent should be analyzed and debated as we inform the necessary adaptation of our systems of care.  We expect to see an incredible amount of variation in ER utilization as the situation unfolds, by specific patient populations, urban vs rural settings, and geography-specific COVID-19 case burden. 

We are encouraged that Datavant has convened a wide variety of industry players to construct a COVID-19 Research Database, a set of de-identified data sets made freely available to enable rapid studies at scale.  The new initiative fills an important gap between quick observations that are available from small sets of real world data and clinical trials, which are robust but slow.

The ER phenomenon we’re discussing is not completely unprecedented. Researchers (and ER staff) have long observed the ‘big game effect’ – where ER visits decline as people defer them to watch their favorite team. (The Health Business Blog first reported on it in 2005: Red Sox’ success eases health care crisis.) Some, but not all, of those visits are avoided entirely without negative consequences. The COVID-19 pandemic provides an opportunity for a much longer time series. Let’s use it as a chance to study what’s going on so we can apply the lessons learned as we emerge.

What could explain sustained, lower utilization of the ER? There are a few possibilities:

  1. Many seemingly serious problems resolve on their own when people just wait. If people avoid the ER out of fear, the ‘tincture of time’ will often do the job.
  2. Less aggressive ambulatory settings are proving effective: the physician’s office, a telehealth visit, or home remedies.
  3. The momentum and logic of the ER setting makes matters seem more serious than they really are. Once someone appears there’s always something to find. (As a doctor colleague once told me, “Show me someone who’s perfectly healthy and I’ll give him a full workup to demonstrate otherwise.”)
  4. The ER is the entry point for admission to the hospital. Under fee for service, hospitals need to admit patients to make money. Depending on the proportion of available beds during these uncertain times, hospitals may be even more economically motivated than usual to fill open beds. So, once a patient arrives, they may be staying.
  5. A significant portion of ER traffic is composed of so-called ‘frequent fliers.’ Usually, they are tolerated, but in the current environment, ER staff are motivated to triage non-COVID-19 patients away from the hospital as efficiently as possible. Once this becomes evident, the ‘frequent fliers’ ground themselves.
  6. How many times have you called your doctor’s office or pharmacy and heard the recording say, “If this is a medical emergency, hang up and dial 9-1-1”? That definitely got people used to the idea that the ER is a good place for care. Clearly people are ignoring that messaging now!

So what should we do with this unexpected information?

  1. More finely tune financial incentives to discourage unneeded utilization while not discouraging needed care. We know from experience that bluntly requiring large patient financial contributions drive down both good and bad utilization.
  2. Educate people about the downside of ER visits (infection risk, treatment that’s too aggressive, likelihood of admission to hospital, provider that doesn’t know you) to balance out the current bias for ER care. People will be more receptive now and won’t immediately think that health plans are only trying to ration their care. 
  3. Consider other changes in benefit design to help the decreased utilization persist, including increased access and reimbursement for home services, telehealth, and remote management tools.
  4. Encourage physician offices and others to make better efforts to intervene quickly and prevent people from going to the ER just for convenience. This could include on-demand availability of telehealth consultations and other digital/remote management for which they would be reimbursed.

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By healthcare business consultant David E. Williams, president of Health Business Group and Surya Singh MD, president of Singh Healthcare Advisors.

Partners dissolves into Mass General Brigham. I’m quoted in the Boston Globe

published date
December 4th, 2019 by

Massachusetts General Hospital and the Brigham and Women’s Hospital joined together as Partners HealthCare 25 years ago. Now they’re changing the name to Mass General Brigham, spending up to $100 million in the process. I’m quoted on the subject in a recent front page Boston Globe article (In major rebranding, Partners HealthCare to change name to Mass General Brigham).

What’s in a name, you may ask? In this case it’s worth parsing the change and exploring the history.

What does Partners mean anyway?

Partners HealthCare never had much brand equity. The word “partners” really described the decision of the two hospitals to partner with one another to offset the power of managed care organizations to play them off against one another. All HMOs needed one of those hospitals in their network, but not both. With Partners it was all or nothing. Partners had no problem playing “take it or leave it” right from the get go, nearly bringing Tufts Health Plan to its knees in the late 90s.

So unlike your typical business combination, which relies on elimination of duplication and other efficiencies to be successful, Partners succeeded right away by virtue of its enhanced market power and high pricing. Duplication remained –and remains to this day. MGH and the Brigham continued to move forward on their own while a new Partners overhead was introduced. No one –not patients, not doctors, not nurses– developed any attachment to Partners as an entity.

Why keep General?

Massachusetts General Hospital has kept the same name since its charter was granted by the Commonwealth of Massachusetts in 1811. It’s a proud name, and maybe sometimes a little too proud. (Some say MGH stands for Man’s Greatest Hospital.)

“Massachusetts” is shortened and “Hospital” is omitted from the new name. Of all the words to keep, why was “General” left intact? It seems so… generic. But it also reminds us of the grand era of American industry. General Motors. General Electric. General Atomics. (Remember that one.) The idea was that the one General company could dominate the industry and we’d all be the better for it.

Outside of this state, errr… Commonwealth, “Mass” doesn’t necessarily mean Massachusetts. It could mean a Catholic Mass or a big pile of something. But MGH is so often referred to here and abroad as Mass General that it must have seemed safe to trim it down officially, since the whole name is long anyway.

Where did the Women go?

How did Brigham and Women’s Hospital (BWH) get its name? Unlike MGH, BWH went through some name changes, although none recently. The Boston Lying in Hospital was founded in 1832 and the Free Hospital for Women came about in 1875. They merged in 1966 to become the Boston Hospital for Women. (Apparently that name didn’t stick right away, since I was always told I was born in the Lying in Hospital –even though I was born after the merger.)

In 1980, the Peter Bent Brigham Hospital, Robert Breck Brigham Hospital and Boston Hospital for Women merged (not partnered) to become BWH.

If they had called it the Women’s and Brigham the Women’s name might have survived the latest consolidation rather than being unceremoniously lopped off.

GSK not G SK

Back in the 1980s and 1990s a lot of big pharmaceutical companies merged. It was typical for them to drop the last name of their multiword names when they did. For example, SmithKline & French became SmithKline Beckman after merging with Beckman and then SmithKline Beecham after merging with Beecham.

When Glaxo Wellcome and SmithKline Beecham came together they followed a similar path. But you may notice they went with GlaxoSmithKline rather than Glaxo SmithKline, because the SmithKline people thought that would make it harder to get rid of their name later on. That’s a true story. I was there.

The stratagem has worked so far.

I wonder whether the BWH folks lobbied for MassGeneralBrigham to avoid a similar fate down the road.

When did Hospital become a bad word?

Remember when there were doctors and hospitals? Now it’s providers, medical centers and health systems. Hospitals still dominate economically and politically, but there is a general (and welcome) shift to lower acuity settings of care. Meanwhile Partners has vacuumed up so many other hospitals, physicians and other players that “hospital” no longer belongs in the name.

An interesting marker of the new company’s brand equity and name recognition is that unlike virtually every other new healthcare organization or company, it omits the word “health” from its name. People already understand it’s a healthcare organization.

What about Harvard?

MGH and BWH are both Harvard hospitals. So why not just call it the Harvard Hospital System or Harvard Health System? The use of the Harvard name could be a topic for its own post (Harvard Pilgrim –originally Harvard Community Health Plan and soon to merge with Tufts but with no name announced yet– is a great example) but the simple answer is that while MGH and BWH are Harvard hospitals, there are others like Beth Israel Deaconess and Boston Children’s that are also affiliated with the University.

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By healthcare business consultant David E. Williams, president of Health Business Group.

What gets measured gets done. So be careful what you measure!

published date
October 21st, 2019 by

When I read ‘Fear of Falling’: How Hospitals Do Even More Harm By Keeping Patients in Bed I was reminded of the old adage, ‘What gets measured gets done.’

In this video I lay out three solutions to the problem of overzealous pursuit of fall reduction:

  1. Keep the measure but change the target so we’re not aiming for zero falls
  2. Add a new measure of how much patients are getting up and walking
  3. Reduce the penalties for excessive falls

What do you think?

By healthcare business consultant David E. Williams, president of Health Business Group.