Post Index (reverse chronological)

Nextera brags about THIS? Really?

In its recent report from KPI Ninja, Nextera Healthcare bragged unpersuasively about overall costs savings and reduced utilization of downstream care services. But they also bragged about the following utilization figures for a group of 754 members for whose primary care they were paid $580,868 in DPC subscription fees over the equivalent of a ten-monthContinue reading “Nextera brags about THIS? Really?”

KPI Ninja/Nextera report: every single cost comparison has an 8.5% benefit design error.

In KPI Ninja’s “School District Claims Analysis” comparing claims costs under the Nextera plan and the competing fee for service (Choice) plan, the “Analyst” overlooked two major differences between the plans in how the “School District” pays “Claims“.   Nextera members pay post-deductible coinsurance at a 20% rate and the district pays an 80% share. ButContinue reading “KPI Ninja/Nextera report: every single cost comparison has an 8.5% benefit design error.”

KPI Ninja’s Nextera risk measurement charade

Abstract: The Nextera “study” by KPI Ninja misappropriated the prestige of a Johns Hopkins research team to support its risk measurement claims; relied on an undisclosed and unvalidated methodology for obtaining population risk measurements; obtained highly dubious risk measurement results; and sharply mischaracterized the significance of those results. In the end, because applying even theirContinue reading “KPI Ninja’s Nextera risk measurement charade”

KPI Ninja’s Nextera analysis: more than enough problems.

Three major adjustments are needed, even without correcting the IP admit rate problem or arriving at a more reasonable risk adjustment. Comparing data from Nextera patients and non-Nextera patients in the SVVSD programs requires three major adjustments which KPI Ninja never attempted. Computations here. Because of the different benefit structures, the district’s claim costs forContinue reading “KPI Ninja’s Nextera analysis: more than enough problems.”

FFS primary care is higher quality than DPC. “Proved.”

One pet theme of most D-PCPs is, “Who can better determine quality better than my patient?”, a question invariably coupled to its speaker’s brag about a high patient retention rate. And yet, in the Union County employee DPC clinic study, the actuaries observed a huge risk selection bias against the DPC, enough to require aContinue reading “FFS primary care is higher quality than DPC. “Proved.””

DPC’s narratives can be just as misleading as their quantitative studies.

Advocates for the DPC movement have many stories to tell the public about how great DPC is. Some of their most potent narratives, however, are as misleading as their slew of quantitative studies. One root cause is that DPC advocates seem unable to imagine anyone else being as clever as they are. The ur-brag ofContinue reading “DPC’s narratives can be just as misleading as their quantitative studies.”

KPI Ninja’s Nextera study: a “single blunder” introduction

The KPI Ninja report on Nextera’s school district program claims big savings when employees chose Nextera’s direct primary care rather than traditional primary care. But the analysis reflects inadequacy of a high order. Here’s a starter course of cluelessness, actually one the report’s smaller problems. The report ignored the effect of an HRA made availableContinue reading “KPI Ninja’s Nextera study: a “single blunder” introduction”

Nextera did not reduce inpatient hospital admissions by 92.7%.

Abstract: KPI Ninja’s report on Nextera’s direct primary care plan for employees of a Colorado school district clinic claims profoundly good results: nearly $1000 per year in savings for every Nextera clinic member and a staggering 93.7% reduction in inpatient hospital admissions. Both claims rest on the proposition that a population of middle-aged. middle-class, white-color,Continue reading “Nextera did not reduce inpatient hospital admissions by 92.7%.”

Nextera’s Next Era in Cherry-Picking Machine Design

Note: revised and redated for proximity to related material. Original version June 27, 2020. In June of 2020, Nextera HealthCare had a hot new brag: These results were not risk adjusted. But they desperately needed to be. The St Vrain Valley School District had this health benefit structure for its employees during the period studied:Continue reading “Nextera’s Next Era in Cherry-Picking Machine Design”

Medi-Share gives its Christian take on DPC downstream cost savings: $31 — a year.

Christian Care Ministry (“Medi-Share”), whose 400,000 members account for more than a quarter of health cost sharing members nationally, recently acted to allow some of its members to receive credit for their entire direct primary care membership fees up to $1800 per year. That there is a certain synergy between DPC and health cost sharingContinue reading “Medi-Share gives its Christian take on DPC downstream cost savings: $31 — a year.”

HSA breaks for DPC defeat the purpose of HSA breaks

HSAs are intended to encourage more cost-conscious spending by placing more of the health care financing burden on out-of-pocket spending by the users of services, as opposed to having the costs of those services incorporated in payments shared over a wider group of plan enrollees regardless of service use. H/T Blumberg and Cope. HSAs areContinue reading “HSA breaks for DPC defeat the purpose of HSA breaks”

Helping those patients most dependent on DPC means defeating the DPC/HDHP/HSA “fix”.

Plus, two more reasons to reject the “fix”. Direct Primary care clinicians and advocates often point out, accurately, that they serve a broad socio-economic range of patients. The range is well illustrated by a pair of oft-appearing themes, “concierge care for the middle class” and “affordable care for those who fall between the cracks”. InContinue reading “Helping those patients most dependent on DPC means defeating the DPC/HDHP/HSA “fix”.”

DPC is way different than you paying Neflix. Notes

The State of New York has the financial capital of the country (arguably the world), has the most insurance companies in the country, and was the biggest state for the longest time. For these reasons it is generally looked to for leadership in the law on financial subjects primarily governed by state law. Here’s theirContinue reading “DPC is way different than you paying Neflix. Notes”

DPC subscriptions transfer financial risk.

Identifying DPC nonsense does not require a law degree. Watch out. Near you is a direct primary care advocate begging a legislator or regulator to make his medical practice less accountable. He is stomping his feet very, very hard and he’s shouting “This is not insurance”, “There is no risk being transferred”, or “My practiceContinue reading “DPC subscriptions transfer financial risk.”

DPC cherry-picking: the defense speaks. Part 1.

Jump to Part 2. Within days of the Milliman report warning of the “imperative to control for patient selection in DPC studies [lest] differences in cost due to underlying patient differences [] be erroneously assigned as differences caused by DPC”, the first rumbling of resistance from the DPC advocacy community emerged. This was a suggestion,Continue reading “DPC cherry-picking: the defense speaks. Part 1.”

Milliman: A $60 PMPM DPC fee buys an employer a zero ROI.

An actuarial study brings employer direct primary care to a turning point. Milliman’s actuaries insisted that DPC cost reduction data without risk adjustment is essentially worthless. A second prong of Milliman’s analysis suggested that the direct primary care model is associated with a 12.6% over-all reduction in health services utilization*. Then, working from that number,Continue reading “Milliman: A $60 PMPM DPC fee buys an employer a zero ROI.”

DPC ultimate goal: capitation without accountability?

Allowing an HSA holder to use pre-tax dollars to buy subscriptions only gets DPC operators so far. The HSA holders would still notice that their paid subscription fees will not actually make a dent in meeting their insurance deductible. DPC advocates will then reprise their perennial theme song, “Insurer’s conditions on payment interfere with theContinue reading “DPC ultimate goal: capitation without accountability?”

Downstream consequences when employers fall for non-risk-adjusted data brags.

Do you remember when Union County’s three year DPC commitment for 2016-2018 was claimed to be saving Union County $1.25 Million per year? So why did Union County’s health benefits expenditure rise twice as fast as can be explained by the combined effect of medical price inflation* and workforce growth? For the first year orContinue reading “Downstream consequences when employers fall for non-risk-adjusted data brags.”

Medicare, dual coverage, and opt-out. The cherry on top of the cherry-picking machine for employer-based direct primary care.

In 2016, the share of people between 65 and 74 who were still working was over 25%. Any of them working at employers with more than twenty employees covered by group health plans are required by law to be included in the employer’s plan. They may also enroll in Medicare Part B. Some employer plansContinue reading “Medicare, dual coverage, and opt-out. The cherry on top of the cherry-picking machine for employer-based direct primary care.”

Two new DPC brags failed to show bona fide risk-adjusted savings; together, they make clear that DPC brags rely on cherry-picking.

Two recent DPC brags fit together in a telling way. Nextera Healthcare reported non-risk-adjusted claims data indicating that employees of a Colorado school district who selected Nextera’s DPC option had total costs that were 30% lower than those who selected a traditional insurance option. But that employer’s benefit package confers huge cash advantages (up toContinue reading “Two new DPC brags failed to show bona fide risk-adjusted savings; together, they make clear that DPC brags rely on cherry-picking.”

Nothing huge, but a possible small win for DirectAccessMD cost reduction claims.

The DirectAccessMD clinic that serves the employees of Anderson County, SC, is run by a tireless advocate for, and deep believer in DPC, Dr J Shane Purcell. Here the employer, with Dr Purcell’s apparent support, has taken steps that seems to have somewhat mitigated the selection bias that is baked into most other direct primaryContinue reading “Nothing huge, but a possible small win for DirectAccessMD cost reduction claims.”

On induced utilization in direct primary care, Milliman replied. I rebutted. NOW I concede.

In a prior post, I suggested that Milliman’s use of downstream claims data in assessing utilization in Union County’s employee health plans may have been distorted in favor of DPC because that downstream data had not been adjusted to reflect the effects of the County’s cost-sharing design on utilization. In a footnote to a recentContinue reading “On induced utilization in direct primary care, Milliman replied. I rebutted. NOW I concede.”

Do bears sh. . .ake cherries out of trees? Selection pressure is built into DPC choices for any population with a normal deductible.

At last, it dawns on me. Selection bias is baked into virtually every DPC cake.* Direct primary care usually comes with a significant price and a package of financial incentives revolving around primary care (and, sometimes, around some downstream care). For some, the game may be worth the candle. The incentives, typically the absence ofContinue reading “Do bears sh. . .ake cherries out of trees? Selection pressure is built into DPC choices for any population with a normal deductible.”

Epiphany. Dr Gross’s risk adjustment metholodogy for direct primary care stands contrary to contemporary understandings of how to assess the relative expected costs of differing populations.

Dr. Lee Gross’s Epiphany Healthcare provides DPC services for some of the employees and some members of of some of their families at a hospital in Florida. Some hospital employees decline Epiphany; they and some members of their families receive instead traditional insurance based primary care. Unusually for such arrangements, a recent assessment of theContinue reading “Epiphany. Dr Gross’s risk adjustment metholodogy for direct primary care stands contrary to contemporary understandings of how to assess the relative expected costs of differing populations.”

CHANGED GRADE: The mixed bag of Milliman earns a final grade: B+

Skillful actuarial work on risk adjustment. A clear warning against relying on studies that ignored risk adjustment. Implicit repudiation of a decade of unfounded brags. An admirable idea on “isolating the impact of DPC model” from the bad decisions of a studied employer. Milliman should have recognized that the health service resources that go intoContinue reading “CHANGED GRADE: The mixed bag of Milliman earns a final grade: B+”

RESCINDED: ATTN: Milliman. An employer’s cost sharing plan affects claims experience.

In its recent assessment of the impact of the direct primary care model, Milliman took a two track approach. An employer ROI based approach included comparing claims experience for a group of employees who opted to receive primary care from a DPC clinic versus those using traditional FFS PCPs; in addition, the ROI analysis alsoContinue reading “RESCINDED: ATTN: Milliman. An employer’s cost sharing plan affects claims experience.”

Did Ratner Industries uncover the secret of health care cost reductions?

To kick off our open enrollment period two years ago, we at Ratner Industries held a company wide employee meeting. There we dusted off our brand new offering of a high deductible plan option. To get a rough idea how many employees planned on electing each option we offered free bags of M&Ms to employeesContinue reading “Did Ratner Industries uncover the secret of health care cost reductions?”

Attn: AEG/WP. Milliman study implies 12.6% downstream care cost reductions for DPC.

The AEG/WP plan still isn’t likely to work. A $95 PMPM fee, increasing at the same rate as other medical expenses, and coupled to a 12.6% reduction down stream would evaporate all of AEG/WP’s claimed billion savings. “Healthcare Innovations in Georgia:Two Recommendations”, the report prepared by the Anderson Economic Group and Wilson Partners (AEG/WP) forContinue reading “Attn: AEG/WP. Milliman study implies 12.6% downstream care cost reductions for DPC.”

Milliman’s valuation of DPC health care services at $8 PMPM rests on faulty data.

If I were a direct primary care practitioner, I’d be mildly miffed at Milliman’s reducing what I do to a series of CPT codes. I’d be more worried by Milliman’s team setting the value of my health care services at $8 PMPM. The $8 PMPM figure Milliman declared as the health care service utilization toContinue reading “Milliman’s valuation of DPC health care services at $8 PMPM rests on faulty data.”

ATTN: Milliman. Even if Union County had not waived the $750 deductible, the County still would have lost money on DPC.

The lead actuary on Milliman’s study of direct primary care has suggested that the employer (Union County, NC, thinly disguised) would have had a positive ROI on its DPC plan if it had not waived the deductible for DPC members. It ain’t so. Here’s the Milliman figure presumed to support that point. It is trueContinue reading “ATTN: Milliman. Even if Union County had not waived the $750 deductible, the County still would have lost money on DPC.”

Risk adjustment, and more, badly needed for KPI Ninja’s Strada-brag

Amended 6/26/20 3:15AM The Milliman report’s insistence on the important of risk adjustment will no doubt see the DPC movement pouring a lot of their old wine into new bottles, and perhaps even the creation of new wine. In the meantime, the old gang has been demanding attention to some of the old wine stillContinue reading “Risk adjustment, and more, badly needed for KPI Ninja’s Strada-brag”

DPC is uniquely able to telemed: a meme that suffered an early death.

An update to this post. Larry A Green Center / Primary Care Collaborative’s Covid-19 primary care survey, May 8-11, 2020: In less than two months, clinicians have transformed primary care, the largest health care platform in the nation, with 85% now making significant use of virtual health through video-based and telephone-based care. Larry A GreenContinue reading “DPC is uniquely able to telemed: a meme that suffered an early death.”

The Nextera/DigitalGlobe study design made any conclusion on the downstream effect of subscription primary care impossible.

The study indiscriminately mixed subscription patients with pay-per-visit patients. Selection bias was self-evident; the study period was brief; and the study cohort tiny. Still, the study suggests that choosing Nextera and its doctors was associated with lower costs; but the study’s core defect prevent the drawing of conclusions about subscription primary care. UPDATED JUNE 2020.Continue reading “The Nextera/DigitalGlobe study design made any conclusion on the downstream effect of subscription primary care impossible.”

Iora’s Las Vegas experience is an inapt model for DPC, and shows no real cost reduction.

While DPC Coalition features an Iora Clinic in Las Vegas as a data model of the joys of direct primary care, it is simply not representative of a general population. That clinic focused on a very high need population, every member chronically ill. We are looking at people with $11,000 claim levels at 2014 prices;Continue reading “Iora’s Las Vegas experience is an inapt model for DPC, and shows no real cost reduction.”

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