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Author: Brian Klepper

By Brian Klepper, PhD   A couple weeks ago, Catalyst for Payment Reform hosted a webinar that provided a glimpse into Walmart’s health care strategy and management plans. Lisa Woods, Senior Director of US Benefits, talked about a new program to simplify and improve health care, particularly...

Brian Klepper, PhD   How will the drive to health care value affect health care’s structure? We tend to assume that the health care structure we’ve become accustomed to is the one we’ll always have, but that’s probably far from the truth. If we pull levers that...

By Brian Klepper, PhD   It’s no secret that conventional U.S. health care arrangements have been ineffective in controlling health care costs. In 2008, the consulting firm PricewaterhouseCoopers estimated that more than half (54.5%) of all American health care spending delivers no value, and health care spending...

Brian Klepper, PhD RAND Corporation recently published a report showing that, on average, private health plans (and the employers and unions that typically sponsor them) pay hospitals 241% of what Medicare pays for the same procedure or service. Of course, there’s lots of variation around that...

Brian Klepper, PhD A couple weeks ago a Journal of the American Medical Association article reported the results of a large (33,000 employees) rigorous study of worksite wellness programs. As explained in The New York Times, the research “found no significant differences in outcomes like lower blood pressure or sugar...

Brian Klepper

A class action legal ruling this month, on a case originally filed in 2014, found that UnitedHealthCare’s (UHC) mental health subsidiary, United Behavioral Health (UBH), established internal policies that discriminated against patients with behavioral health or substance abuse conditions. While an appeal is expected, patients with legitimate claims were systematically denied coverage, and employer/union purchasers who had paid for coverage for their employees and their family members received diminished or no value for their investments.

Central to the plaintiff’s argument was the fact that UBH developed its own clinical guidelines and ignored generally accepted standards of care. In the 106 page ruling, Judge Joseph C. Spero of the US District Court in Northern California wrote, “In every version of the Guidelines in the class period, and at every level of care that is at issue in this case, there is an excessive emphasis on addressing acute symptoms and stabilizing crises while ignoring the effective treatment of members’ underlying conditions.” He concluded that the emphasis was “pervasive and result[ed] in a significantly narrower scope of coverage than is consistent with generally accepted standards of care.” Judge Spero found that UBH’s cost-cutting focus “tainted the process, causing UBH to make decisions about Guidelines based as much or more on its own bottom line as on the interests of the plan members, to whom it owes a fiduciary duty.”Read More

Brian Klepper

A year ago, 92 primary care physicians (PCPs) in Charlotte, NC broke away from the region’s largest health system, Atrium Health, forming Tryon Medical Partners, an independent, physician-owned group. Then, a couple weeks ago, another 41 PCPs left the area’s second largest health system, Novant, to join Holston Medical Group, a large multispecialty physician practice with more than 80 PCPs headquartered in nearby Kingsport, TN.

In these and most primary care breakaways from large health systems, the complaints are generally the same. Within a fee-for-service, volume-driven environment, primary care’s role, at least in part, is to capture patients and feed the machine. Health systems pressure PCPs to refer patients internally as often as possible for lucrative diagnostics and procedures.Read More