Insurance Companies V. Doctors

According to the article “seguradoras responsabilizan a los médicos de sus pérdidas” by Marga Parés Arroyo, published on the newspaper El Nuevo Día on January 25, 2017, insurance companies allege that doctors are the cause of their losses.

Two insurance companies have emitted guidelines which affect the Medicare Advantage Program. According to the article, Triple-S sent a doctors a letter on December in which they were informed of the amendments in their contracts in order for to make them take responsibility for the mismatch of funds that companies has annually, starting on January 9, 2017. Víctor Ramos, President of the College of Doctors, stated that due to the amendments in the contracts of physicians with Triple-S, they would be paying up to 25% of the deficit that the insurance company incurs due to a mathematical or actual error. The amendments allow Triple-S to billed doctors for any deficit up to 16 months after the end of the year. Ramos, also indicated that the doctors who rejected the amendments, received a second letter from Triple-S where they were requested to reconsider their position, something Ramos has interpreted as the possibility that their contracts with the insurance company be cancelled.

The article also indicates that Triple-S and MCS have decided not to comply with some increases in the Medicare Advantage Program for 2018 according to the Geographic Pricing Cost Index, a calculation through which Medicare and Medicaid repay doctors. According to Ramos, Triple-S and MCS have indicated that they will be amending the list of prices of Medicare to those of 2016 in order to not pay the increase in payment doctors will be receiving for the procedures done in 2018.

Ramos stated that this situation will make the number of doctors fleeing from Puerto Rico to increase. Carlos Mellado, ex Advocate of the Patient, stated that everything that affects the practice of medicine will have an increase in the exodus of doctors from Puerto Rico and that insurance companies need to be regulated.

Medicare Patients Dying After Leaving Hospitals

According to the article “Medicare patients death shortly after leaving the ER raises questions about rural hospitals” by Casey Ross, published on the StatNews website on February 1, 2017, questions regarding staff and treatment of patients in rural hospital have been raised after a study brought to light the deaths of patients beneficiaries of Medicare after being discharged. According to the study, more than 10,000 Medicare patients, who do not have life-threatening conditions, die annually around 7 days after being discharged from hospitals.

The study has also risen questions regarding rural hospitals’ adequate resources and if the Government’s intent on lowering costs has had an impact on basic and essential care. It is no secret that under the Affordable Care Act hospitals have to treat patients efficiently while having to reduce admissions which are considered unnecessary. This in turn has resulted in the discharge of patients and exploring outpatient treatment as an option. According to Dr. Rade Vukmir, fellow of the American College of Emergency Physicians, has stated that Medicare and private insurers’ strategies regarding admissions and discharge have had an impact on decision-making.

According to the article the study shows that there is a higher rate of unpredicted deaths in low admission hospitals than in high admission hospitals. Dr. Zaid Obermeyer, an emergency medicine physician and professor at Harvard Medical School, states that “it doesn’t seem that the deaths are due to random chance. There is something different going on in those low-admission-rate hospitals.” Obermeyer also stated that there are several factors that may cause this problem, such as limited staffs, fewer transportation, problems with hospital protocols, and not necessarily can providers be attributed the cause.

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