Jeffrey Epstein, MD, is well acquainted with dichotomies. For eight years from 1998 through 2005, Dr. Epstein served as a part-time medical director for Blue Cross of Philadelphia while also operating his own private internal medicine practice. By comparison, Dr. Epstein says that was a cake-walk compared to the new challenge of juggling fee-for-service and value-based payment.
As one of 40 to 50 physicians that dedicated 20 hours per week to utilization review for Blue Cross of Philadelphia, Dr. Epstein became intimately familiar with the criteria and protocols used by health insurers. He would joke with his practice staff that he might admit a patient to a local hospital in the morning, and then go to his afternoon job and deny their admission.
Forced to reconcile his two roles, Dr. Epstein tried to practice medicine the way he though was best, and made sense for the insurance company. If he saw a hospital patient who might go home the same day based on some pending test result, Dr. Epstein would write the necessary prescriptions and complete the necessary forms in anticipation of the event. Then when the test results returned, the patient could be discharged immediately rather than the next morning.
“It took a little extra time and organization,” says Epstein. “I knew how insurance wanted things done, and how I did things. I just put them together. I found out you could practice medicine the way they wanted.”
Dr. Epstein says most denials that he observed for hospital care were related to delays. This might include patients that sit around in a hospital on Saturday or Sunday and receive no care. He rationalized these denials as the application of pressure to the system to make health insurance premiums more affordable for everyone. They were an incentive to improve efficiency.
“I always tried to do the right thing,” say Dr. Epstein. “Ninety percent of the time there was a clear right or wrong answer. If there was a delay in getting a stress test, that day was denied. I really do feel like most cases are clear cut. Five or 10% of the time there is not a right and wrong answer, but two correct answers. Sometimes the problem was that the physician did not document completely so you were not aware of all the problems and all the risks. I always felt that poor documentation led to poor care, so I enjoyed denying cases with poor documentation to send a message to the providers.”
Dr. Epstein found that health insurance was generally reasonable in its desire to apply evidence-based medicine in its coverage policy, although it sometimes moved slowly compared to its network clinicians. Medical underwriting guidelines like Interqual and Milliman were great tools for the insurance companies.
“With Milliman it really made sense. I really felt good,” says Dr. Epstein. “They’re intended be used as a level one screening tool—not an end all. If patients meet certain criteria, they are definitely sick enough to be in the hospital. If they don’t fit the criteria, they may still be sick enough to be in the hospital, they just don’t fit the criteria.”
Since leaving Blue Cross and private practice in 2003, Dr. Epstein has continued to perform utilization reviews on the provide-side in medical director roles at Morristown Medical Center, Stamford Hospital, and Winter Haven Hospital. His job involves deciding whether they should appeal a denial or not with MACs, RACs, or commercial insurers.
During his time at Morristown, the system’s physician president believed strongly and deeply in accountable care organizations (ACOs), and intended to participate in Medicare’s program regardless of how the upside or downside risks were eventually resolved. Morristown was part of the first group of Medicare ACOs in April of 2012. Dr. Epstein found that the process of getting community physicians involved in the ACO was very cooperative, collegial, creative, and a lot of fun. However, he believes the blend of fee-for-service hospital reimbursement with small shared savings creates the wrong incentives.
“The problem with ACOs initially, and still, is that the current fee-for-service environment pays when patients are in the hospital. We’re trying to live in two universes with different gravity,” say Dr. Epstein. “The ACO felt right and it is how we should practice medicine, but there is still more of an incentive to have patients in the hospital than not.”
During his tenure at Morristown Dr. Epstein tackled heart failure with the goal of preventing readmissions, and even preventing admissions from occurring in the first place. Heart failure is the most common reason for patient admissions under the Medicare program and one of the most costly diseases to treat on an annual basis. According to the Care Continuum Alliance, per member per month treatment costs of $2,700 are not uncommon.
However, with ACO participants being paid FFS reimbursement, and only 50% of the shared savings being split amongst the entire network, the bulk of payments still come from FFS reimbursement. The stakes become even higher when the full downside risk applies after the third year of the program. If ACOs don’t have three years to work out the kinks in their model, the downside risk is a coffin nail.
“In some ways having two masters is not a bad thing when you can satisfy both of them,” responded Dr. Epstein. “But with fee-for-service and value-based payment, you get split in two.”
————————————————————————————————- Jeffrey Epstein, MD, is the founder of The Epstein Group and also serves as a medical director for Winter Haven Hospital in Florida. He can be reached at JeffreyEpstein@gmail.com or 863-293-1121 ext. 6859.