Colorado Health Exchange Premiums Dropping – by a Lot

With the development of the health insurance exchange, prices for coverage for those in Colorado are going to drop. This will give families an average of $600-$700, back in their pockets. Read the article below to see when and how this new change will take place.nnFor the first time since Colorado opened its health insurance exchange, the prices people pay for coverage will drop — by a statewide average of 20.2%.nnAnd for families in western Colorado — who face some of the highest health insurance premiums in the nation — the savings could total more than $10,000 per year, according to final numbers for 2020 released by the Colorado Division of Insurance.nn“Just imagine: What could you do with that in your life?” Gov. Jared Polis said. “What could your family do with an extra $600 to $700 a month?”nnThe biggest reason for the price drop — which was higher than projected — is reinsurance, a bipartisan program created by state lawmakers during the 2019 session.nnThe program is basically a pool of $260 million in state and federal money that Colorado plans to use in 2020 to help cover some of the most expensive medical bills from the 250,000 people who buy plans through the state’s individual market. In exchange for the help, insurance companies lowered their monthly premiums.nn“It’s the same plans,” Polis said. “It’s just lower prices.”nnThat means problems such as people not using their insurance because of a high deductible will still exist, but the governor is hopeful that the lower monthly costs will lower the state’s uninsured rate.nn“We think this prices it into the market for many more families,” Polis said, though he didn’t commit to a specific number.nnDetails on the plan options can be found at, with 2020 enrollment beginning Nov. 1.nnThe state lawmakers behind the reinsurance bill told The Denver Post they’re not done working on health care costs, either.nn“We have to attack the basic underlying costs,” said Sen. Bob Rankin, R-Carbondale. “This bill does not address why health care costs so much.”nnHis counterpart in the Colorado House, Rep. Julie McCluskie, D-Dillon, is optimistic about programs such as a public option and something called an alliance model that’s just starting in Summit County.nnPeak Health Alliance is a group of big employers that banded together to negotiate lower prices from their local providers and used those prices to get better rates from health insurance companies. When combined with the reinsurance reduction, McCluskie said, alliance members will see their premiums cut up to 50% next year.nnThe governor hopes that by 2021, many more of these alliances will exist, including a statewide group with state, county and city public employees.nn“There’s absolutely significant upside to an alliance model everywhere in our state, both the regional models and statewide,” Polis said. “We’re aggressively pursuing those opportunities to save people money.”nnOriginal article published on

ICM Coding

In this code spotlight, Welter Healthcare Partners is providing new information regarding ICM Coding. Read below to find out more information on Insertable Cardiac Monitor codes!nnnOne of the hardest parts of coding is the revolving door of code changes.  2019 saw a change to Insertable Cardiac Monitors or ICM. Codes 33282 and 33284 were deleted and replaced with 33285 and 33286.  In addition to revisions to the guidelines and monitoring codes there is a lot to read. Here is a great chart to help you get through your next ICM encounter.nn

Wasteful Spending in U.S. Healthcare Estimated at $760 Billion to $935 Billion

For 2019, the U.S. is projected to have spent $3.82 trillion on healthcare. No other country in the world spends this much on healthcare. Below we assess the data and see what the research is saying regarding healthcare prices in the United States. Continue reading to find out more on this wasteful spending.nnnWaste accounts for about 25% of U.S. healthcare spending, new research indicates.nnNo other country spends more on healthcare than the United States, with the gross domestic product share of healthcare spending estimated at nearly 18% and rising. Earlier research on U.S. healthcare spending has estimated that waste accounts for about 30% of the spending total.nnReducing wasteful spending is a promising avenue to curb annual increases in the country’s healthcare spending, according to the co-authors of the new research, which was published today in the Journal of the American Medical Association. “Implementation of effective measures to eliminate waste represents an opportunity reduce the continued increases in U.S. healthcare expenditures,” the researchers wrote.nnThe researchers examined data from 54 published reports. They tallied waste in six categories identified in 2010 by the Institute of medicine (IOM): failure of care delivery, failure of care coordination, over-treatment or low-value care, pricing failure, fraud and abuse, and administrative complexity. Pricing failure includes medication pricing, payer-based health services pricing, and laboratory-based and ambulatory pricing.nnIn 2019, total U.S. healthcare spending is projected at $3.82 trillion.nnThe JAMA researchers generated several key data points:nnAnnual wasteful spending on healthcare is estimated from $760 billion to $935 billion.nnInterventions to reduce waste in the six IOM categories would result in annual savings from $191 billion to $282 billion.n


  • The annual cost of wasteful spending from administrative complexity accounts for the highest category of waste, estimated at $265.6 billion.
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  • The annual cost of waste from pricing failure is estimated from $230.7 billion to $240.5 billion.
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  • The annual cost of waste from failure of care delivery is estimated from $102.4 billion to $165.7 billion.
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  • The annual cost of waste from overtreatment or low-value care is estimated from $75.7 billion to $101.2 billion.
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  • The annual cost of waste from fraud and abuse is estimated from $58.5 billion to $83.9 billion.
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  • The annual cost of waste from failure of care coordination is estimated from $27.2 billion to $78.2 billion.
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nThe impact of likely interventions to reduce wasteful spending are significant but limited, the researchers wrote.nn”The best available evidence about the cost savings of interventions targeting waste, when scaled nationally, account for only approximately 25% of total wasteful spending. These findings highlight the challenges inherent in rapidly changing the course of a health system that accounts for more than $3.8 trillion in annual spending, 17.8% of the nation’s GDP.”nnAssessing the datannThe highest amount of wasteful spending was associated with the administrative complexity category. The development and adoption of value-based payment models has the most potential to impact this category of wasteful spending, the researchers wrote.nn”In value-based models, in particular those in which clinicians take on financial risk for the total cost of care of the populations they serve, many of the administrative tools used by payers to reduce waste (such as prior authorization) can be discontinued or delegated to the clinicians, reducing complexity for clinicians and aligning incentives for them to reduce waste and improve value in their clinical decision-making.”nnReducing spending the second-highest wasteful category—pricing failure—poses daunting challenges because of the rising prices of pharmaceuticals, the researchers wrote. “New high-cost specialty drugs, which will soon exceed 50% of pharmaceutical spending, are raising new questions about how to maintain affordability. This topic has thus received considerable attention from policy makers, and numerous proposals are currently under consideration.”nnThe researchers say strategies to ease cost pressure in pharmaceuticals include increasing market competition, importing drugs from countries with lower medication prices, and reforming price transparency.nnThe big picture viewnnAn editorial accompanying the new research says the findings are a significant contribution to the ongoing effort to rein in the country’s healthcare spending.nn”At a time when the United States is once again mired in a great debate about the future of its healthcare system, the data reported in the article … should become part of the national discussion. It would be nearly impossible for all waste to be eliminated in any healthcare system, just as it is impossible to know the true cost of any change in the delivery and financing of healthcare without understanding possible savings, and recognizing that there is complexity in knowing the savings,” the editorial says.nnConcentrating on wasteful spending is crucial, the editorial says. “While no single solution will solve the continuous increases in U.S. healthcare spending, identifying, reducing, and eliminating waste are important and appropriate places to start.”nnOriginal article published on

Operative Report | Converted Laparoscopic

Do you have a complicated surgery case that needs help with coding? Welter Healthcare Partners would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected.nn– Click Here to Submit Redacted Surgery Case Study –nnDATE OF PROCEDURE: October 2017nPREOPERATIVE DIAGNOSIS: Acute diverticulitis.nPOSTOPERATIVE DIAGNOSIS: Acute diverticulitis with obstruction.nESTIMATED BLOOD LOSS: Minimal.nCOMPLICATIONS: No immediate complications.nnDESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was taken to the operating room and laid in supine position. General endotracheal anesthesia was induced. Pre-op antibiotics were given. An infraumbilical incision was made. This was carried down through subcutaneous tissue and fat until I arrived at the fascia. Incision was made in the fascia. A 10-12 port was inserted into the abdomen. The abdomen was insufflated with CO2. I placed 3 other 8 nun ports. The robot was then docked. I then proceeded with an extensive lysis of adhesions. I dissected out the sigmoid colon. There was a large amount of chronic inflammation. I dissected down to just above the rectum and I dissected up toward the descending left colon. Once I had completely dissected and freed out the majority of the diseased portion of the sigmoid, I used the robotic stapling device and I fired this proximal and distal to the diseased portion of the colon. An incision was made in the suprapubic area. The colon was removed out of the abdomen. I checked to make sure I had adequate hemostasis. I then proceeded to dissect down the descending colon attachments so I could bring this down toward the remaining Hartmann pouch. I dissected as much as I could of the lateral peritoneal reflection. However, I did not have adequate length in order to provide a tension-free anastomosis. Therefore, I had to convert to an open procedure, making a lower abdominal incision. I was then able to dissect out the remaining lateral peritoneal reflections up to the splenic flexure. This gave me adequate length in order to bring down my descending colon for my anastomosis. I used a pursestring device on the very end of the left descending colon. I placed an anvil after sizing the anus and rectum with the EEA. The EEA device was then placed from the anus into the rectum. The pin was fired just anterior to the staple line. The anvil was placed down with the descending colon. The EEA was fired. I did reinforce portions of my circular anastomosis with 3-0 silk suture. I checked to make sure that I had adequate complete donuts, which I did. I irrigated out the abdomen. I approximated and closed the fascia using a running #1 PDS suture. I irrigated out the subcutaneous tissue. I approximated and closed all incisions with staples. The patient tolerated the procedure well.nn10/2017 – Lab Report: SURGICAL PATHOLOGY EXAMnnNote: All result statuses are Final unless otherwise noted.nnTests: (1) SURGICAL PATHOLOGY EXAM (SURG)nnSpecimens: A) – Large Intestine, Sigmoid ColonnB) – Large Intestine, Sigmoid Colon, ANASTOMOTIC RINGSnnFinal DiagnosisnColon, sigmoid, segmental resection:nnDiverticular disease complicated by acute diverticulitis, diverticular abscess, and acute serositis with adhesion formationnNo dysplasia or malignancynnColon, sigmoid, anastomotic rings, resection:nnTwo fragments of colon wall without significant pathologic abnormalitiesnNo dysplasia, acute inflammation or malignancynnClinical Information Diverticulitis with abscessnnGross DescriptionnReceived in formalin and labeled with the patient’s name and medical record number are two specimens.nnReceived is a portion of the sigmoid colon measuring 20.5 cm in length and varying from 2.0 to 4.0 cm in diameter. Serosa coating the segment of bowel is showing focally yellowish discoloration, fibrin adhesions and hemorrhage. Definitive perforation site is not grossly identified.nThe specimen is opened and reveals numerous diverticular openings.nLocated in the center of the specimen is an area of marked stenosis with only about l cm of open luminal diameter. Sectioning through the segment reveals numerous diverticular openings. Several of the diverticular openings extend to close proximity of free serosal surface that is coated with fibrin and hemorrhage. Definitive microabscesses are absent.nMultiple representative sections in total of five.nnReceived are two anastomotic rings measuring 2.5 x 2.2 x 1.7 cm and 1.4 x 2.0 x 1.5 cm. Representative section of each submitted in two.nnMicroscopic DescriptionnA, B. Microscopically examined.

Does Value-Based Pay Have a Future?

Private payers have begun to embrace the possibilities of value-based care. Many are not including value-based incentives, which allows the patient to save money. Read the article below to find out more on how this value-based pay system has a future.nnValue-based care has created a conundrum: pretty much everyone in healthcare likes the idea of paying for outcomes, but no one is sure how to fairly implement it.nnThe Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) introduced a new world of value-based care to many physicians and was a major step away from fee-for-service. Gone was the Sustainable Growth Rate, replaced with a program that was supposed to drive costs down by reimbursing for quality patient outcomes.nn“Congress had revised the Sustainable Growth Rate many times over the past 20 years, and everyone was fatigued by it,” says Larry Kocot, JD, head of KPMG’s Center for Healthcare Regulatory Insight and a former CMS official. “Physicians were willing to take something new to not have to go through that exercise again.”nnDoctors suddenly found themselves trying to navigate new MACRA acronyms like MIPS and APMs to figure out where they fit as Medicare started moving away from fee-for-service in a bid to contain costs and improve care quality.nnAt the same time, more private payers began to embrace the possibilities of value-based care, working incentives into contracts that rewarded physicians who could use data to show patients were healthier and avoiding unnecessary hospitalizations. But fee-for-service contracts are still the norm.nnMeanwhile, physician organizations began to push back against MACRA as their members rebelled against the cost of the technology needed to comply and the complexity of the reporting measures. CMS responded by exempting hundreds of thousands of physicians, causing some to question the value of the program and if it was improving patient care or saving money.nnWith MACRA now a few years old, experts are looking at how it might be reformed, and what value-based care might look like in the future.nnMACRA: a misstep toward valuennMACRA has not worked to the extent policymakers hoped, says Frederick Southwick, MD, a practicing internist and healthcare researcher at University of Florida Health.nn“The goal was to drive a significant wedge in payments between those willing to step up and use Alternative Payment Models and those who remained on the sidelines,” says Southwick. “We’ve seen physicians take a shot on some things they might not have done in the past to get a bonus payment, but they have not reached the point where they’ll feel pain if they don’t. The MIPS side of this was supposed to be painful to physicians, but it’s mostly a big nothing-burger because so many have been excluded.”nnAs a result, there isn’t much money in the budget-neutral program to move from the poor performers to the good performers, eliminating much of the incentive. According to CMS, in the 2019 payment year (based on 2017 performance data), 71 percent of MIPS participants received a positive payment adjustment with a bonus for performance, 22 percent received a positive payment without the bonus, 2 percent didn’t receive a positive or negative adjustment and only 5 percent received a negative adjustment.nn“The more physicians that are excluded, the harder it is for those in the program to win,” says Kocot, noting that the maximum payment adjustment anyone received was 1.88 percent, while the maximum penalty was 4 percent.nnMIPS was intended to be the incentive to get physicians into some form of risk-sharing APM, but MIPS isn’t accomplishing that and the 5 percent positive payment adjustment APM participants can earn expires in 2024.nn“What is the incentive to get people into MIPS and into an APM as we move further down the line?” asks Kocot.nnMIPS also faces the problem of how to define “quality”.nn“Healthcare is so complicated, that’s hard to do,” says Chris Dawe, vice president of Evolent Health, which helps providers and health plans transition to value-based care, and a former health policy adviser in the Obama administration. “The best way would be through knowledgeable consumers who would ask questions about the cost-benefit and is it worth it to their health and wellbeing. The problem with that is patients don’t go to medical school.”nnEven if patients were making decisions, they would still have difficulty determining who the best doctor is because of the lack of objective information, and in many regions, the absence of choices in hospitals or physicians.nnMIPS participants have scored well on quality measures, but many doctors argue that the measures don’t have any connection to real-world medicine. The time spent reporting on quality has also proven burdensome for many, who say it takes more time away from patients and redirects money toward IT projects.nn“All of these initiatives require a tremendous amount of data accumulation and manipulation,” says William Spratt, Jr., JD, partner in the healthcare practice of Akerman LLP, in Miami. “There are so many different metrics and different ways to modify and manipulate the data in order to determine whether they are meeting various criteria or not, it’s challenging.”nnFor physicians without the support of a larger organization, the challenges are even greater. “It’s introduced an awful lot of complexity into the practice of medicine,” says Spratt. “It’s hard for them to change their practice administration in order to measure and hit those targets.”nAn unintended consequence of that difficulty has been an increase in physicians affiliating with health systems and hospitals so as to shift the reporting burden.nn“It’s probably strengthened the hand of the health systems and offers them another carrot for the primary care physician,” says Southwick. “They aren’t necessarily acquiring them, but at least getting them in the network. I don’t think this is what Congress had in mind.”nnHe adds that a lack of vision has hampered the success of programs like MACRA, because no one understands the end goal.nn“I’ve never heard anyone from the White House articulate what this should look like in five to 10 years,” says Southwick. “Doing so would help the market work toward that and be ready for this new world. Instead, we are just going from one program to the next. It would be a benefit if CMS would say what this would look like at the end.”nnThe future of value-based carennStill, while MACRA may not be working out as envisioned, many experts say it is an important first step toward implementing value-based care. “MACRA started the conversation,” says Spratt. “It has started moving medicine toward more value-based payment and away from the traditional fee-for-service model, which I think most policymakers realize is a good approach.”nnDespite the struggles of MACRA, experts say physicians should understand that their revenue from fee-for-service will continue to decline.n“From what I have seen, the transition to value-based care is a given,” says Andrei Gonzalez, MD, assistant vice president at Change Healthcare, a company that helps payers and providers move to value-based care. “It’s more about what are the right models and how are we going to get there?”nnWith CMS rolling out its new Primary Care First initiative, Gonzalez says their intent is clear. “They want to blow up fee-for-service, and the primary care initiative is a big step in that direction.”nnThe initiative encompasses a variety of models. It is expected to cover about 25 percent of Medicare beneficiaries, and include removing coding requirements for primary care physicians by paying a monthly per-patient fee or a flat per-visit fee.nnPrivate payers are creating similar programs, and large employers are asking commercial plans to use some of CMS’s strategies to save money. As a result, more private payer contracts are including value-based incentives.nn“I do think the private sector push will make it easier as clinicians see value-based care as the new normal and are subject to quality and cost targets that are not fee-for-service,” says Kocot. “That’s absolutely essential to the transition.”nnBoth public and private payers realize they need multiple plans in order to succeed, says Gonzalez.nn“Our research has shown that different models work for different conditions and different regions,” he says. In areas where there is a lot of consolidation among providers and health systems, ACOs or full capitation—where physicians receive a flat monthly fee for each patient— will make the most sense. In less-consolidated areas, models like the Patient-Centered Medical Home may be the primary option.nnWhile capitation was tried in the early days of HMOs, Gonzalez says the industry is a lot savvier on how to do it now. Payers and providers both are going in with more caution. Physicians are managing a patient population, but understand they will need to meet quality and cost metrics, although not the full risk burden like in the past.nnSpratt says smaller practices may need to affiliate with a hospital or health system, because payers see value in partnering with organizations with large numbers of physicians, ancillary services and even urgent care centers, because it gives them more control over the insured and better management of the premium dollar.nn“At the end of the day, it’s all about integration and the coordination of care,” says Spratt.nnCare coordination includes practices being more proactive with helping patients to lead healthier lifestyles and not just waiting for the patients to reach out to them.nn“A lot of practices already have this mentality, but it creates the need for a different set of aptitudes within the practice,” says Gonzalez. This could include, for example, having a nurse monitor COPD patients and ensuring they come in for regular visits.nnFuture value-based care models will also have a greater focus on the social determinants of health.nn“One thing value-based care leads us toward is a sort of untethering of the physician from historical medical tools and allowing them to think more holistically,” says Spratt.nn“Physicians will need to start figuring out how to help patients manage their conditions, how to navigate the health system and manage the social determinants of health,” says Gonzalez. “It’s not as big of a change as it seems, because not every patient requires assistance, but practices need the ability to identify who needs extra help.”nnThe role of the primary care doctornnNo matter what models emerge, experts see the primary care physician as the team leader. Dawe says the patient-centered medical home, with a primary care physician working with one or two NPs or PAs, a nursing staff and someone that goes into the community to help educate patients on how to manage their diseases is a good model, as is an ACO.nn“I think the basic structures for a good model are already in place,” says Southwick. “You can go a long way to creating a new payment ecosystem just on the basis of a primary-care based model, which is basically an ACO.” If that is combined with bundled payments for specialists, Southwick says, those two models work very nicely together.nn“The primary care physician has to be central to any aligned payment and care coordination working with the patient from start to finish,” says Kocot.nnBut primary care doctors should also expect to take on more risk-sharing with payers, whether it’s through an ACO or some other payment model. He warns the transition must come with assistance.nn“There’s a lot happening that primary care physicians have to process on a daily basis,” he says. “The transition needs to be moderated so we don’t lose them in the process. The CMS burden reduction program is very positive, but we have to strike the right balance of incentives and push, and I don’t know that we have yet.”nnExperts say that value-based care will continue to become more prominent in contracts, even though programs like MIPS might be revised or replaced in the future. But one thing is for sure: there is no hiding from it.nn“The move to value is alive and well,” says Kocot.nnOriginal article published on

Changes and Ways to Stay up to Date

Health Care is a revolving door of changes and unlike most professions, some of our biggest changes happen on a yearly basis. The plus side to this is that we can anticipate most these changes and start preparing for them. How can you make the most out of these changes and make sure you’re ready when they happen? The quick answer is to be prepared, but sometimes that is easier said than done.nnThe important thing to remember, is that these changes are typically finalized months in advance. You start to see industry buzz about proposed changes and this is the time so start paying attention. As we continue to move forward, there are great resources out there to take advantage of and not all of them come with a price tag. Podcasts have come a long way and are not just This American Life, and you don’t need a smart phone to access them. Often times you will end up finding a voice that you can really connect with. Best part is that we are not talking about 2+ hour long webinars. Often times these are quick, 30 minute conversations about key take a ways. With a 30 minute run time they can be great items to listen to while driving, on lunch breaks or even while doing those mindless household tasks.nnOne great weekly option is Talk Ten Tuesday. Click here to see more about the podcast!