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Medical Tourism

Domestic Medical Tourism on the Rise

An increasing number of employees are being faced with a question when it comes to non-emergency surgical care: stay close to home and pay a portion out of pocket, or travel to another U.S. facility and pay nothing?

In an effort to control the rising costs of health care, more employers are implementing surgical benefit programs that encourage their employees to receive care at facilities with proven outcomes, even if they’re hundreds of miles away. It may seem counterintuitive that the employers are sending their employees to the best facilities in the country and saving money at the same time. But, as one industry insider said, it’s indicative of a health care industry that has a flawed pricing system and a lack of transparency.

“Given the bizarre pricing model that exists for health care services in this country, there is actually a negative correlation between quality and price,” said Terry White, president of BridgeHealth Medical, a surgical benefit management company in Denver, Colo.

Also referred to as “medical tourism,” the trend of employees traveling for care is catching on among self-insured employers. Some of the largest companies in the U.S. including Walmart, Boeing and Lowe’s, are giving their employees the option of traveling, sometimes hundreds of miles away, to get care from facilities considered to be the best in the nation.

A Burgeoning Industry

The trend has also led to the rise of companies such as BridgeHealth that broker these deals for the employers.

Employers and brokers look to facilities that have proven outcomes for particular procedures. They negotiate bundled, fixed-rate prices that are generally 20 to 50 percent below rates charged through traditional insurance plans. BridgeHealth guarantees its clients that the cost savings will at least equal the fees they pay to BridgeHealth. “But, beyond that, we think it’s achievable to reach [savings up to] ten times.”

White said while well-known brands, such as the Mayo Clinic or Cleveland Clinic, are known for their quality, there are also small facilities that have top quality scores but not the name recognition the larger facilities might have. Facilities in BridgeHealth’s network are always rated in the top 25 percent for the particular procedure covered by the plan, White said.

Quality of care directly impacts the amount of money an employer can save, explained Jonathan Edelheit, CEO of the Medical Tourism Association, a trade group for medical tourism companies. The hospitals with which employers negotiate are so confident of their outcomes, the negotiated rate usually includes any additional costs that may arise from complications. Fewer complications mean less recovery time and less time away from work, Edelheit said.

The medical tourism trend started several years ago with a focus on the international market. The focus has since shifted to domestic travel.

An Easier Sell

White said traveling within the U.S. is an easier sell to employers and their employees than international medical tourism was. It’s also a better business model, he said. Companies like BridgeHealth can assess the quality of stateside hospitals much easier than those abroad because of the quality reporting requirements in place in the U.S., according to White.

White said there’s been a steady uptick in the domestic travel industry over the past couple of years. Not only are more employers adding surgical benefit options to their employee health plans, but long-term BridgeHealth clients are adding more procedures to their benefit packages.

While there will always be a population of people unwilling to travel for care, others are being enticed by waived co-pays and deductibles. Many companies are also covering the cost of travel for the patient and a companion and a few even offer cash incentives to those willing to travel.

Closer-to-home Options

Thomas Johnston, CEO of EmployerDirect Healthcare, an Austin, Texas-based surgical benefits provider, said his employer clients have found that while many patients are willing to travel for care, they are unwilling to get on an airplane. Most of the agreements his company brokers are between companies and health care providers that are within a 100-mile radius of one another. Johnston said EmployerDirect looks first at the surgeon, analyzing data including patient volume, complication and infection rates. The chosen surgeon then helps negotiate a bundled rate at a facility he is contracted with.

Johnston is betting that finding closer-to-home options will ultimately lead to growth in the medical tourism industry. Given the increased interest expressed by employers, Johnston is forecasting his company will double the number of lives covered next year to reach half a million.

Edelheit expects to see an overall 20 percent increase in the number of employers implementing medical travel programs in 2014. Many were watching from the sidelines as Lowe’s and others implemented their programs, he said. As those companies expanded their offerings, the ones watching and waiting started to ask how they, too, could implement similar programs.

“The other reason domestic medical tourism is really going to take off is health care reform doesn’t lower costs,” Edelheit said. “It doesn’t reform medical malpractice, pharmaceutical and medical supply costs. So as the costs are going up and employers see it and know it’s coming, they have to do something innovative to lower the costs,” he said.…


Cut Out the Copying and Pasting in EHRs!

For busy physicians trying to make efficient use of electronic health records (EHR), employing the “copy and paste” feature to transfer information within a patient’s record is a time-saver. Also known as cloning, it’s a common practice among 74 to 90 percent of doctors, according to the American Health Information Management Association.

But instead of being the model of efficiency, the habit is being targeted as a potential cause of medical error and fraud.

Cloning is so pervasive and troubling, it drew the attention of Kathleen Sebelius, secretary of the U.S. Department of Health and Human Services, and Attorney General Eric Holder. They jointly wrote a stern letter to industry medical groups warning physicians to stop copying and pasting information in EHRs. They reported “troubling indications that some providers are using this technology to game the system, possibly to obtain payments to which they are not entitled.”

The HHS Office of the Inspector General also named EHR copy/paste practices as one of its top challenges last year. It noted that cloning could lead to improper payments or inaccurate information in patient records. It’s no small problem.

The Journal of the American Medical Informatics Association reports that 54 percent to 78 percent of physicians’ notes contain copied text.

Many health care leaders bristled at the accusation of fraud, including Rich Umbdenstock, CEO of the American Hospital Association. While cloning and upcoding should not be tolerated, he wrote, “it’s critically important to recognize that more accurate documentation and coding does not necessarily equate with fraud.”

Worst Practices

There are multiple ways doctors use cloning, such as copying information from a past office visit and pasting it into the record for the new encounter. The problem—and what generates fraud concerns—is that payers could get billed for a service that was done initially but not during the most recent visit, says Ivy Baer, senior director and regulatory counsel for the Association of American Medical Colleges in Washington, D.C.

“It also can lead to poor quality patient care. You’re not getting an accurate note about what happened during that visit,” Baer says. “We want to look at the note and know what’s going on right then and what the treatment plan is. I don’t want to discount the potential for fraud, but it’s a quality of care issue first and foremost.”

Cloning also can cause doctors to repeat errors in a patient’s file.

Todd Searls, director of Wide River, an IT health care consultancy in Norfolk, Neb., gives an example: One doctor mistakenly notes that a patient has a history of cancer. Even if the doctor quickly corrects the error in a note amendment, it could get repeated by another physician who clones the original history. This practice has all sorts of insurance, billing, treatment, and financial implications, and the doctor could be liable for not taking the patient’s history anew, Searls says.

Doctors who copy/paste could set themselves up for an audit by the Centers for Medicare and Medicaid Services, and they should view Sebelius and Holder’s letter as a warning to clean up their practices, Searls says.

“Most of this really isn’t fraud—maybe they could prove it in about 1 percent of cases. But they want to raise the alarm and get the message out that they are going to dig into this practice.”

Some Solutions

To avoid an audit, it mostly comes down to training physicians to stop cloning. Instead, Baer says, doctors should cite references, date included, to previous visits or lab results that are pertinent to the current complaint.

Additionally, EHR vendors should develop features that turn copy/paste material into a different color or font, making it obvious that the information came from a past visit. There also should be a way to tell who wrote which portion of a note, adds Baer.

Health care organizations can work with their EHR vendor to turn off certain functions if they encourage cloning or automatic billing, says Searls. They also should create policies and train physicians on what is appropriate. Finally, have compliance officers review patient records and billing to make sure the billing codes actually reflect patients’ visits, he suggests.

Overall, this can lead to better health care practices. “In the end we really do want a good note and a good health record, and I think that’s what physicians want, too,” Baer says. “They need to appreciate the value of that, and the cloning and copying and pasting is unlikely to get them there.”…

Medical Response

Haiyan: Coordinating an International Medical Response

Thousands are feared dead in the aftermath of what could be the worst storm ever recorded, Typhoon Haiyan.

The scattered dispatches from the central Philippines region describe scenes of devastation, fields strewn with dead livestock, and air thick with the stench of rotting flesh. Piles of human corpses line roads.

At the height of the storm, scientists recorded sustained wind speeds up to 200 mph, enough to knock out many main line communications hubs.

Rescuers are struggling to reach some towns and villages, since parts of the worst-hit areas had tenuous infrastructures to begin with. As natural disasters like Hurricane Katrina, Hurricane Sandy and Typhoon Haiyan ramp up in intensity and often hit densely populated areas, how do international relief organizations coordinate a response?

Getting Our Bearings

Before targeting relief and aid, we must first know the scope and breadth of the damage. With Google Maps, satellite imagery and crowd sourcing more accessible than ever, mapping storm damage in real-time has never been better.

Speaking of that giant San Francisco-based tech giant, Google has a philanthropic arm,, with a barrage of crisis response tools available to help coordinate first responders anywhere in the world.

Google Crisis Maps has a crowd sourced map of evacuation centers, crisis centers, hospitals and emergency supply drop zones throughout the Philippines.

Also tapping into the knowledge of the crowd, Personfinder helps concerned families and friends find information about missing loved ones. Anyone can search for the name of a missing person or add information about someone who is missing. Google has a dedicated page for “Yolanda,” as the storm is called in the Philippines.

Outside of Google, OpenStreetMap has a continuously updated Wiki of information on the storm, maps, and links to other data sources.

Moving People and Aid to the Area

Once we can see how severe the damage is and where, the next step will be getting lifesaving resources to the country.

With many roads, bridges and airports devastated and communications down, that can be tougher than it seems. The Tacloban City Airport control tower has been turned into a makeshift hospital, the BBC reports, and not just to treat storm-inflicted injuries.

Dialysis patients and other chronic care patients still need daily or weekly medicines and treatments, but the storm has prevented these types of treatments.

One survivor described the scene in Tacloban “like God has just scrubbed off the mountains.”

Direct Relief allows good Samaritans to donate money by credit card or PayPal to world disaster relief generally or Typhoon relief specifically.

Coordinating an international effort

“We need to focus on getting shelter kits, water and health services on the ground,” Justine Greening, Secretary of State for International Development in Great Britain told Dan Damon of the BBC World Service.

“We’re making sure supply lines are cleared and that any working airports are taking military aircraft full of supplies,” she said.

Economically poor places like the Philippines suffer more devastation that other places in the world, she said.

“Looking ahead, the key to success is making sure that the relief work we do now is disaster proof for the future,” she said.…


Reference Pricing: Another Tool That Saves Money, or a Limitation on Care?

Setting caps on medical costs may save us money… but not without sacrifice.

In 2010, the California Public Employees’ Retirement System (Calpers) made a big move to rein in how much they were spending on hip and knee replacements. They capped the amount they would pay after noticing a shocking disparity in prices for the same procedures throughout their state.

At the low-end, they were paying out $20,000, and at the high end, $120,000 for a retiree’s new knee. So-called “reference pricing “ is being seriously suggested as a potential solution to our countrywide problems with overpriced health care.

“Reference pricing is very, very simple, easy for everyone to understand and that’s what makes it so powerful,” says Timothy Tyler Brown, associate director of research at the Berkeley Center for Health Technology and co-author of a study on the Calpers reference pricing plan.

Price Caps

The idea behind reference pricing is this: a standard price is set for a medical good or service. The payer (usually an insurance company) covers this standard price, anything more than that must be paid by the patient. In the case of the Calpers study, payers agreed to $30,000, which was about the mean cost of the procedures statewide.

In the first year alone, charges for joint-replacement surgery to Calpers dropped 26 percent.

Brown’s study looked at pricing and consumer choices from 2008 to 2012 in the Calpers system. The year before reference pricing was introduced, 48 percent of Calpers patients chose low-price hospitals. The year after, that number jumped to 63 percent.

Perhaps a more surprising effect was that the hospitals began to move their prices toward the cap amount. In the first year alone, charges for joint-replacement surgery to Calpers dropped 26 percent. Two years post-reference pricing, Calpers had saved nearly $6 million.

Another study of this situation, conducted by the health outcomes research group HealthCore, found the patient outcomes to be similar or better in the low-cost hospitals. Now, the retirement system is looking to cap costs on other procedures.

The Down Side

The results from this study are no doubt impressive but, although reference pricing is easy to understand, it is somewhat complicated to implement.

“The key issue with reference pricing is, effectively, you need to have two services or products that are clinically identical,” says Lorens Helmchen, associate professor of health administration and policy at George Mason University. This need for equivalency limits where reference pricing can be applied. It is already in common use for pharmaceuticals and Brown sees it being applicable to standardized procedures such as cataract surgery and colonoscopies. However, other procedures — such as cancer surgeries — vary widely and it would be difficult to identify what qualifies as the standard form.

“We want people to get what they need but make sure that they’re getting it at a place that gives the highest amount of value.”

There may also be push back from certain medical providers and patients. Helmchen says that the high-priced providers will likely try to argue that their service differs from the standard and should therefore not be included in the cap price. Patients, he says, may also argue that their good or service of choice is superior to the standard and feel cheated when they have to cover the cost difference.

Costlier Options Remain

While patients may be miffed about a perceived infringement on their options, Brown points out that reference pricing is neither meant to limit choices nor discourage the use of medical goods and services. He compares reference pricing to Preferred Provider Organizations.

If people want to choose a hospital that will charge above the reference price, it’s similar to people who choose doctors outside of the PPO. They can make that decision but they will pay extra for it.

“We want people to get what they need but make sure that they’re getting it at a place that gives the highest amount of value,” says Brown.

Reference pricing is not widely used yet and Helmchen says we’re still a ways away from that happening. But both Brown and Helmchen agree that it’s part of a bigger movement toward transparency in medical pricing.

“If [a] consumer is exposed to at least a fraction of the cost differential then that should engender some more critical review of the effectiveness relative to the cost of these alternatives,” says Helmchen.

Reference pricing may not end up the pricing strategy of choice, in fact you may not ever hear about it again, but with our country’s ever-rising health care tab, increased consumer knowledge of health care cost seems all but inevitable.…