Healthcare services, tech & policy nerd. Alum: @theNAMedicine, @StanfordEng, @SAISHopkins, @CMCnews, @BCG and various health services & tech cos. Views my own.
California, USA
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In @nejmcatalyst, @ALKaplan_MD and I tackle the #Covid shock to hospital & physician practice finances.
As Warren Buffett says, "when the tide goes out, you find out who's been swimming naked"
Or, in this case, who has bet heavily that prices & volumes will only ever go up. 1/n
The Covid-19 pandemic has highlighted the urgent need for health care providers to abandon volume-based payments in favor of models that give them financial stability in volatile times. catalyst.nejm.org/doi/full/1… #COVID19 #SARSCoV2
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Solution hierarchy for surprise billing:
1 - No arbitration; just use a transparent benchmark, as in MA
2 - Bundle professional fees into the hospital pymt
3 - Arbitration *by CMS itself*
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876) Bonanza for lawyers, private “arbiters,” and a handful of medical groups
I dug into the finances of the three nonprofit arbitrators resolving No Surprises Act disputes. For every dollar they made in '25, ~half was pure profit.
Read more about these 'mini-gods' and how they're getting rich off their new jobs.
tinyurl.com/5ye2csun via @statnews
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In DC, I’m often struck by how static & outdated many policy takes seem to be.
Perfect ex here. CA created the first Medicaid managed care model in the ‘70s, and a majority of enrollees have been in mgd care for ~30 yrs
If it saved taxpayer $$, we’d know healthaffairs.org/content/fo…
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One illustrative recent lit summary here.
aeaweb.org/articles?id=10.12…
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At one level, insurers’ focus on C-SNPs seems simple - higher margins.
But our prior should prob be that higher margins stem mainly from selection & risk coding effects.
And if MA plans are picking the most profitable cells on a risk map, that may not be healthy for the market.
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Today's exercise in the absurdity of Medicare Advantage networks:
Optum insisting it doesn't accept UHC MA PPO members, while clearly listed in UHC's directory for that exact plan.
Can we get some of these supposed benefits of vertical integration, along with the obvious harm?
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This quote from BCBSA - about the "disconnect between diagnoses and treatment" - is undoubtedly true and blindly ironic.
Adding diagnoses for untreated conditions is EXACTLY how insurers boost their own payments from taxpayers (in Medicare Advantage). 🙈
The Blue Cross/Blue Shield Association says that AI is already driving *up* healthcare costs, as hospitals use the technology to find instances where they can bill more for the same level of care. bcbs.com/about-us/associatio…
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To take one example at random, here is @OIGatHHS detailing a long list of diagnoses that BCBS of Alabama submitted for conditions without any evidence of current treatment.
Minor stuff, really. AMI. Colon cancer. Breast cancer. Sepsis. What have you.
oig.hhs.gov/documents/audit/…
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Undoubtedly true. And also suggests an awfully limited horizon, even if you only care about margins.
Hospitals spend far more on, say, radiology & lab techs as they do for in-house billers. If you want to move the needle on profits, AI has to reach the clinical services.
Every health system IT or clinical informatics leader is telling me they’re under immense pressure to adopt AI. When asked for the top area of focus, roughly 75% have told me it’s the rev cycle.
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Remarkable summary in @TheEconomist of the (many) surgical procedures that appear no better than non-operative care (or placebo).
Appendectomy, meniscal “repair,” spinal fusion, rotator cuff…🤯
Many surgical interventions are little better than placebo
economist.com/science-and-te…
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I hadn't seen this 2025 @OIGatHHS report on managed care and behavioral health before.
Who knew that Medicare Advantage plans perform so much worse than Medicaid HMOs on BH access?
And 55% inaccurate? Why let insurers market taxpayer-funded plans with such misleading info?
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Dan O'Neill retweeted
🚨 ADHD and Autism rates- Real or Inflated? 🚨
Diagnoses have skyrocketed over the last 20 years. Are we detecting missed cases, or broadening diagnostic criteria?
By tracking polygenic scores across two cohorts totaling over 37,000 diagnoses, we finally have a biological answer.
New in @JAMAPsychiatry 🧵
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Dan O'Neill retweeted
Thanks to the RGJ for letting my friend Dr. Raman and me discuss how @aboutKP has destroyed long-term doctor-patient relationships here in my hometown in Northern Nevada. rgj.com/story/news/health/20…
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Three opinions about unpaid medical bills:
1) In most cases, aggressive collections are immoral.
2) Reliance on collections often indicates shoddy or incompetent operational mgmt.
3) Given the error rates in medical billing, its not clear that the word "debt" is appropriate.
New exclusive: In his 25 years as an OBGYN, Sen. Roger Marshall of Kansas repeatedly sued patients for outstanding medical debt. At least 81 were arrested during their court proceedings. Some had debt from c-sections; others from miscarriages.
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To supercharge this experiment in decoupling health insurance from work...
...let employees use tax-free $$ from the employer to buy into the state Medicaid program at full actuarial value for adult enrollees.
Several hundred dollars cheaper each month than a commercial plan.
So long, ICHRA. Hello CHOICE.
The individual coverage health reimbursement arrangements formerly known as ICHRA now have a less icky sounding name.
cms.gov/marketplace/employer…
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This is a worthwhile critique of managed Medicaid, and the shared savings idea is good.
I’d pose two broader Qs:
1 - Is there any evidence that managed care ⬆️ quality or ⬇️ taxpayer cost? If not, what are we doing here?
2 - Why not just do shared savings w/out the middlemen?
🚑 @BudgetHawks is out with a new Medicaid paper 📝
The “Medical Loss Ratio” rules for managed care plans drive up health costs rather than limiting admin costs.
We propose a way to fix that: crfb.org/papers/improving-ac…
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Interesting study, for those interested in the potential (and limits) of cash-pay healthcare.
-Almost 40% of academic urology groups could not give the patient a clear visit price (vs. 15% of private practices)
- In 5 states, median cash pay price is >$400; in 15, it is $300+
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Very useful study by @AJHolmgren and colleagues. I'd take a mildly contrarian view on this, in two ways:
1) This does not seem like a hugely burdensome amount of messages or time.
2) Existing primary care codes (incl E/M) already fund time outside of the visit fairly well.
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To be sure, these aren't perfect - CCM doesn't work for healthy hypochondriacs, and some plans don't cover the codes. But most healthy patients don't generate much non-visit work anyway - in this study, ~75% of patients sent zero messages and the avg was 1.75 msgs/patient/year.
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