R&R Insurance Blog

Accountable Care Organizations, or ACOs, are certainly the buzz word in healthcare. If you are a healthcare provider and serve at least 5000 medicare patients, you are either thinking about, talking about, or considering joining an ACO. In preparing for a recent presentation at the WMGMA on this topic, I had to wonder how this idea originated and what was the intent of the lawmakers who put ACOs into motion.

The idea of managing care is not new.
HMOs began in the early 1970s as an alleged cost cutting tool. Where HMOs served a large population of patients and had an insurance risk bearing function, ACOs are designed for a smaller number of patients and have no insurance risk bearing function inherent in the structure.

To give some context to where we are today, we need to go back to 2005 and the Deficit Reduction Act. At that time the government was looking to replace the Sustainable Growth Rate (SGR) formula that was being used to pay physicians under Medicare Part B. In the Act, they instructed Medpac (the Medicare Payment Advisory Commission) to come up with an alternative method. Congress was interested in substituting the SGR with a method that would break the physicians into “pools” that were smaller than the entire population of US physicians that treat Medicare patients. The theory was that if they could group physicians into smaller groups and subject them to spending caps, the caps would work better at controlling costs than the SGR.

Medpac held a public meeting in November, 2006 and Dr. Elliott Fisher, Director of the Center for Health Policy Research at Dartmouth Medical School, presented to the commission. It was during the question and answer period of the meeting that the term “accountable care organization” was first known to be used.

Dr. Fisher and a number of colleagues published an article in December, 2006 entitled “Creating Accountable Care Organizations: The Extended Hospital Medical Staff, a new approach to organizing care and ensuring accountability”. In this article they discuss the problem with the healthcare system is the “disjointed, and poorly coordinated care that patients receive as they move across settings and among providers, more frequent and flawed care transitions, failures of communication, and errors. “

In April of 2009 Dr. Fisher was asked to appear before the US House Committee on Ways and Means. In his testimony before the committee Dr. Fisher testified that he and his colleagues believed that the lower quality and worse outcomes experience by Medicare patients were largely a consequence of a payment system that reinforced fragmentation and rewarded the growth of profitable but unnecessary services. He suggested that in order to improve quality and slow spending growth the following 3 principles must be embraced:

1. Foster the development of integrated and organized local care systems with a strong foundation in primary care.
2. Move rapidly toward performance measurement that fosters accountability for care coordination, health outcomes, and overall cost of care.
3. Shift toward a payment method that rewards value. Better care, Better Health, Lower Cost.

An Accountable Care Organization is one approach to meeting these goals.

For those providers that are familiar with the proposed rules for forming an ACO released by Health and Human Services on March 31, you can certainly see how the government is attempting to put theory into reality.

Wisconsin Insurance Commissioner Ted Nickel reminds and encourages consumers to make sure their insurance policy is up to date before the rainy season starts. "Many consumers don't realize that a flood insurance policy has a 30-day waiting period before it becomes effective," said Nickel. "Consumers need to act soon in order to have the protection in place by the time spring arrives."

Wisconsin's recent experience with flooding should serve as a reminder to everyone that you don't need to live in a flood plain to be exposed to flooding. Every year since 2007, there has been flooding in the state serious enough to cause significant damage, some serious enough to result in federal disaster declarations.

According to FEMA, there were less than 16,500 flood insurance polices in force as of September 30, 2010. While there was 3% growth in the number of flood insurance policies sold in Wisconsin for the same period, "We need to do better," said Nickel. "There is too much exposure and not enough coverage."

The standard homeowner's policy does not cover damage to property and possessions in the event of a flood. Just a few inches of flood water can cause thousands of dollars in damage.

Flood insurance is relatively inexpensive and is available under the National Flood Insurance Program (NFIP), a federally-backed program managed by the Federal Emergency Management Agency (FEMA). Under the flood insurance program, coverage may be purchased as long as the property is located in a community that participates in the NFIP. To verify if a community participates, check with a property insurance agent or visit the FEMA Website. Information on the program can be obtained by calling 800-427-2419 or visiting www.floodsmart.gov.

If you are Wisconsin resident and would like to know more about flood insurance for your personal insurance package contact a knowledgbroker.

After the devasting effects of a fire, resist the urge to start the cleaning process right away. Improper cleaning can actually cause additional damage, rendering some items unrestorable.

Things To Do:

• Open windows for ventilation if weather permits
• If it is winter and the heat is off, pour antifreeze in toilet bowls, tanks, sinks, and tub drains to prevent freeze damage. Call a plumber to drain water lines because water pipes can cause additional damage if they burst.
• Relocate pets to a safe environment
• Empty refrigerators and freezers if electricity is off. Prop doors open to allow air circulation.

Things Not To Do:

• Turn on any electrical appliances until they have been cleaned and checked.
• Use food items or canned goods that have been exposed to heat
• Attempt to wash fire residue from walls, ceilings and other surfaces.

For more great tips and info go to www.kelmann.com or contact your Knowledge Brokers

Water Damage can happen due to storms, broken water pipes, clogged drains, broken appliances, roof leaks, sewer leaks and more. Water damage requires fast action.

Here are some ways to minimize your damage before professional help arrives:

Do's

• Always use rubber gloves to protect your hands & rubber boots to protect your feet and legs.
• Damage from water and bacteria growth can begin within hours. Call for professional help. Remove as much water as possible by mopping and blotting with sponges.
• Pull up wet rugs and carpets if hardwood floors are below.
• Lift draperies off the floor, loop through a coat hanger and place the hanger on the drapery rod.
• Wipe furniture, prop up wet furniture cushions for even drying and place aluminum foil under furniture legs.
• Move photos, paintings, art objects, computers, other electronics and valuables to a safe, dry location.
• Do not remove books from shelves. Pack them tightly to prevent page warping until a restoration professional can begin this specialized drying.
• Ventilate wet areas. Turn on air conditioning for faster drying in summer (only if there is no visible mold) and winter, alternate cycles of opened windows and heating. Also, open drawers, closets and cabinet doors to enhance drying.

Don'ts

• Do not enter rooms where there is wet and sagging ceiling!
• Do not enter a room with standing water until electricity has been turned off.
• Do not use a regular household vacuum to remove water.
• Use heat to dry closed building interiors. Mildew and more moisture damage can occur.
• Do not use electrical appliances while on wet carpet or flooring.
• Do not disturb visible mold.

For Wisconsin residents, contact a KnowledgeBroker at R&R Insurance for information on protecting your home from water damage, floods, broke pipes. We do offer sewer backup endorsements and have up to date information for flood zone residents, including the new cost-saving flood insurance from FEMA.

Information taken in part from ServiceMaster Clean website.

Allegations of Billing Fraud- In the form a Medicare, medicaid or commercial audit, hospitals are under constant threat of investigations that could lead to costly legal expenses as well as enormous fines and penalties. Government agencies, private consulting firms, patients and employees are targeting the healthcare industry for allegations of fraud.

FFActs plus expands coverage beyond governmental audits and provides defense costs for commercial payor investigations for billing fraud. The program will continue to cover fines and penalties and related defense costs for government audits (Medicare/Medicaid).

For more information please contact a knowledgebroker.

LOST TIME

A “Lost time” claim is one where the WC carrier made a payment to the employee for either wage loss or permanent disability.

WAITING PERIOD

Wisconsin WC statute has a 3 day waiting period before an employee will be paid wage loss benefits by the carrier and the date of injury is not included. This waiting period only applies within 7 calendar days from the first time the employee missed work due to the injury. If the disability occurs beyond 7 days the waiting period is waived.

Nine out of ten WC claims that go sour were reported late.

For prompt reporting to be effective, your goal should be to have 90% of all of your incidents reported before the end of the shift. Notice we say “all incidents.” We did not say all claims. An incident may not result in a claim for medical treatment or disability.

For more information please contact the knowledgebrokers.

What Gets Measured Gets Done!

Accountability has to start at the top and move down.

• Up to whose expectations do employees perform?
• Has the leader’s role in safe behavior been defined?
• Do those leaders understand their role?
• Do you know what is being measured or what should be measured?

Accountability is the backbone of all successful safety programs

What must be in place (the backbone) to hold someone accountable?

For example:

A curfew for your kids

• Do you want a curfew (Decision)
• Set a time (Policy)
• Tell them frequently (Communication)
• Explain why (Relation to outcome)
• Stay awake until they are home (Measure it)
• Accountability (Reward/Consequence)

For more information contact the knowledgebrokers

WC Claim Reserves Cost You Money!

What is the balance in the WC claim "check book" when your loss history is reported to the Rating Bureau?

The entire cost of a claim, including the unspent reserves will impact your experience modification. It is critical that these reserves be reviewed prior to the data being reported to the WC Rating Bureau.

When is the data reported?

What is a claim reserve?

To find the answers to these questions and more information please contact a knowledgebroker.

Medical Only vs. Lost Time Claims

Lost time claims have a significantly larger impact on your MOD and your WC premiums than medical only claims.

What does a $2,500 claim cost in premium?

Why the difference?

To find these answers and know more please contact a knowledgebroker