Tag: vaccines

Vaccine reimbursement is equal across providers and insurers. What if we did the same for all care?

April 5th, 2021 by
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What adjustments are needed?

A seemingly straightforward story caught my eye last week: all Massachusetts providers are being paid the same, generous fee for COVID-19 vaccine administration (Boston Globe). The fee is essentially identical whether the patient has Medicaid, Medicare, commercial insurance –or no insurance. And it doesn’t matter whether the shot is given in a pharmacy, clinic, community hospital, or academic medical center.

It seems logical and makes intuitive sense to the average consumer. But for those in the healthcare field, it’s pretty radical! After all, reimbursement rates for commercially insured patients are usually a multiple of what Medicaid pays and substantially higher than Medicare. And providers and insurers exert extreme efforts negotiating rates (and then trying to keep them secret). Some providers use their market power to drive harder bargains, and insurers do the same.

Bottom line: Reimbursement rates are all over the map, varying wildly depending on who’s the provider and who’s paying. A 2020 Health Care Cost Institute study provides some detail.

This reality has shaped and distorted the US healthcare system:

  • Providers avoid Medicaid patients to cherry pick those with commercial coverage
  • The true cost of Medicaid (and to a lesser extent, Medicare) is obscured by cross-patient subsidies
  • Providers use their market power to extract higher rates, and generate reimbursement ‘synergies’ by acquiring providers with weaker negotiating positions or reclassifying  physician offices as hospital ‘facilities’ that generate their own upcharges
  • Patients get treated in settings that maximize providers’ margins rather than where it’s best for the patients
  • Health plans merge to bulk up against provider systems
  • Health disparities are exacerbated as poorer patients are worth less to providers and get lower priority
  • Tremendous administrative costs are expended to manage the complexity, exploit the rules and search for those who are bending or breaking them

It’s tempting to think we could reform healthcare payment by using this COVID-19 vaccine approach for all reimbursement. But the vaccine is a special case, because there is a specific, national objective to get as many people vaccinated as quickly as possible to end the pandemic and because vaccine administration is pretty simple. Lots of providers are capable of it, and there are unlikely to be differences in outcomes based on provider experience or setting. Across the political spectrum, there is genuine agreement that we want everyone –including poor people and immigrants regardless of status– to get a shot or even two. And we’re happy for providers to prioritize vaccination by allowing them to make good money doing it.

Those conditions don’t hold generally in healthcare. Still, I am in favor of policies that encourage or mandate reducing the gaps in what providers are paid for the same service. There should be a convergence between Medicaid, Medicare and commercial rates, and reimbursement should not vary so dramatically by provider or setting of care.

New approaches, like alternative payment models, often bake in the fee-for-service biases. They shouldn’t.

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

COVID-19 vaccinations are going poorly in MA. I’m quoted in the Boston Globe

January 29th, 2021 by

For months we’ve been focused on the shortage of COVID-19 vaccine doses. That’s still a problem, but for now the bottlenecks are further downstream. Massachusetts is struggling to get the doses distributed and administered. More than half sit unused. Even if we have 10 million (or a billion) doses we’d still be stuck.

In today’s Boston Globe (State’s hope of vaccinating almost everyone by the end of summer depends on a lot going right) I encourage the state to assume there will be enough vaccines and just get them out to people.

“We’re only using half of what we’ve been given,” said David Williams, president of Health Business Group, a Boston management consulting firm. “It’s not an excuse to say because supplies are slow, we can just sit back. We should assume there’ll be more supply, and we owe it to the citizens of Massachusetts to be ready when it comes.”

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

Why is Massachusetts failing at COVID-19 vaccination?

December 28th, 2020 by

Israel (population 9M) has already vaccinated 200,000 people against COVID-19 with the Pfizer/BioNTech vaccine and expects to be injecting over 100,000 per day shortly.

Massachusetts (population 7M)  has injected only 35,000 so far. Here, as in many other states, half the doses are being saved as boosters and not injected out of fear that a future supply glitch could delay dosing from a supposedly magical 21 or 28 day target time.

In Israel, senior residences had multiple stations manned by the local equivalent of the Red Cross, and military personnel with medical training are being used as well. Israel is prepared to ramp up to a 24/7 vaccination schedule if needed. They are treating it as an emergency, which it clearly is.

In Israel, the teams are equipped with epinephrine to handle the occasional severe reaction, which seems to be an issue with both the Pfizer and Moderna vaccines.

Meanwhile, what is the actual logistical plan in Massachusetts? It seems pretty vague. I’ve heard from friends at Boston teaching hospitals (and read in the press) that distribution is a mess. There is general talk of drugstores like CVS and Walgreens providing shots. Are they going to be ready with epi-pens or just call 911?

And what about the idea of giving one shot instead of two if supply is tight? We might get to herd immunity faster if we applied creative approaches such as this one.


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

When will COVID-19 vaccine become available?

July 24th, 2020 by

Operation Warp Speed promises a vaccine in no time (or at least before the election). Is that a pipe dream? And when the vaccine does arrive, how well will it work? How will it be priced? Who will get it? And what will the impact be on the rest of the drug and vaccine market?

John Driscoll and I argue it out in the latest edition of #CareTalk.



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