This article originally appeared at Healthcare Dive on Feb. 15, 2016.

A recent UCLA study concluded nearly 75 million U.S. adults are being misclassified as healthy or unhealthy based on Body Mass Index (BMI) and argued healthcare and health insurance entities should strictly utilize “actual health markers.” This comes after the U.S. Equal Employment Opportunity Commission recently proposed rules that would let employers penalize their staff for as much as 30% of their health insurance costs if they don’t satisfy 24 health criteria, including BMI.

The question now is whether the study will nudge wellness programs, payers and providers toward abandoning BMI as a health measure, and what that would mean for the healthcare industry.

While on the one hand, it seems stakeholders should be interested in improving the accuracy of their patient data, cost estimates, employee charges, etc., some may find it disruptive to move to other health measures and resist.

A brief history behind the measurement

The measure, which is calculated by dividing a person’s weight in kilograms by the square of their height in meters, was invented in the 1800s as a way to gauge obesity in the general population but was not intended to measure individuals, critics argue. They say in large groups the errors tend to cancel out but when applied to individuals, it’s hit or miss because it does nothing to distinguish between bone, muscle and fat. So while the measure tends to correlate with obesity in many otherwise very average people, it fails for many others—most notably those who are particularly muscular, such as athletes, or those who have lost muscle, such as the elderly.

At least one cynic suggests the inaccuracy is part of the appeal, as it benefits employers to target healthy individuals alongside the unhealthy for higher payments or penalties.

A question of legality

Attorney David M. Kaufman, a Partner in the Healthcare Practice Group at Freeborn & Peters LLP and the former General Counsel of Blue Cross & Blue Shield of Illinois, tells Healthcare Dive programs that continue to reply on BMI could ultimately face legal challenges.

He notes the purpose of a wellness program is to improve the health of employees and to reduce healthcare costs, and that federal regulations require they be reasonably designed to promote health and prevent disease.

“A program relying on an inappropriate metric would not meet the standards for such a program and could subject the program or the regulation to legal challenge,” Kaufman says. “Healthcare entities generally support the practice of evidence-based medicine and to the extent that BMI is determined to be an inappropriate metric by which to measure health, relying on BMI would not support the goals of a wellness program.”

What are the alternatives?

Given that BMI is simple and familiar, and therefore well-entrenched, its elimination could indeed cause some disruption and require revisions. “However, BMI would not be the first measure of health considered to be valid only to be discredited later,” Kaufman adds.

Hembroff argues modern technology and 3D scanning capabilities make Body Volume Index (BVI) a more accurate and complete alternative, and it can be done with relatively inexpensive devices such as the Microsoft Kinect. “BVI can look at an individual’s body and weigh fat distribution in problematic areas such as abdominal volume to gain a more accurate assessment of a person’s health. Although not perfect, BVI is a more accurate measurement than BMI,” he says.

Sonic Boom Wellness CEO Danna Korn is also a vocal proponent of abandoning BMI.

“It’s about time,” she says. “It’s crazy that we’re holding onto an inaccurate measure all of these years.” Korn says Sonic Boom Wellness grudgingly uses BMI as a measure because it’s so commonly expected, but the company tries to downplay it and “put a whole lot of caveats around it.”

She suggests it can even be dangerous to use BMI because of the way it can target some who should not try to lose weight.

“There are far more accurate ways to get a measure of whether a person is overweight,” she argues. While some alternative health measures may be costly, she champions the simple waist to hip ratio. “It’s not expensive to do it, we can implement it relatively easily, and it’s far more accurate than a BMI,” she says.

She suggests it will take time to see change, noting authorities including the NIH and CDC still legitimatize the use of BMI, though they do acknowledge its limitations. Any entities that want to hold onto BMI may be able to point to such leading authorities until any sweeping new guidelines are made.

“I think what you’re going to find is that people keenly attuned to accuracy are going to embrace this,” Korn says, “but a lot of major organizations will find it hard to change their metrics.”

This article originally appeared at Healthcare Dive on Feb. 22, 2016.

As hospitals and other providers increasingly offer patients the opportunity to pay cash for services up front for a discount that makes it attractive to bypass their insurer, several experts weighed in with Healthcare Dive on the implications.

The idea is that hospitals save on administrative costs and efforts, while patients get a better deal than their insurer’s negotiated rate. Some argue insurers benefit as well, because they get to collect premiums without paying out as often.

However, the pros and cons are a bit more nuanced. Experts note that while the practice of bypassing insurance is perfectly legal, providers need to check whether undercutting their own negotiated rates violates any of their insurer contracts, and in either case, consider the potential implications.

How hospitals could be impacted

Vizant COO Angie Grunte has been hearing about the practice and sees a possible trend. “I can’t really tell you what we’ll see in the long run,” she says, “but we are seeing it more and more and it’s becoming more of a conversation point.”

She suggests it can have meaningful financial implications for hospitals and providers to receive payment at the time of service rather than having to wait, but that providers have to take care with how they determine their discount and be very specific about what they define as cash payment. Many providers and patients may be interested in using FSA and HSA cards, which are considered the equivalent of cash, as well as debit and credit cards. However, there are costs associated with those cards, Grunte notes.

“You’re going to have to be very cognizant of costs associated with those payments and very calculated in using the timing and the cost to set the discount,” she says.

Gary Sastow, a partner at Brown, Gruttadaro, Gaujean & Prato PLLC (BGGP), raises concerns about the potentially negative impact the move could have on a provider’s relationship with insurance carriers.

“The hospitals and doctors who are doing this would need to make sure it is not violative of their contracts with the various insurance carriers,” he says. Even assuming it doesn’t violate any terms, providers should be prepared for the possibility that insurers may take the position that they will reimburse based on the lower fee, and argue that it supercedes any previously negotiated fee because there can only be one, not two different fees for insurance-using patients and cash-paying patients.

Sastow suggests insurers could even reach back several years and try to demand the return of sums paid in the past. If nothing else, providers can expect insurers to try to change what they’ll pay in the future. “It certainly will dramatically affect future negotiations,” Sastow predicts.

Although he has not personally encountered such legal arguments yet in this context, Sastow says he has seen some related issues around providers waving co-insurance amounts or other fees and anticipates that some waves are going to be made over the issue.

How patients will could be impacted

Although offering patients a cheaper rate appears beneficial on the surface, it puts them in a position that can potentially cause confusion and disadvantage to those who would be better served by paying toward their insurance deductible. It’s a decision that some may not fully grasp on the spot or that others would prefer to have time to weigh.

While providers do not technically owe customers any guidance, it could prove a sticking point.

“Should providers discuss the implications with these cash customers? Yes. But do they?  Probably not,” says SOLIC Capital Senior Managing Director Robert Annas, on the healthcare team at the restructuring firm and investment bank, who has also been watching this trend.

Rebecca Palm, co-founder and chief strategy officer of copatient, a healthcare expense management company that helps patients understand and manage their healthcare expenses, offers advice from the patient perspective.

She warns patients to be wary of any deal in which they are pressured to make a decision at a time when urgent treatment is needed, and to only consider it if they will have ample time to make a decision and consider their overall healthcare spending for the year.

“However, the hard part can often be determining what you would  pay based on your health plan coverage so you can truly compare the costs,” she notes.

Palm adds this type of arrangement may undermine a patient’s ability to manage their medical bills because they don’t apply to their deductible or out of pocket maximum calculations. “If they pay these fees and then subsequently need additional care, they may end up paying more than they had budgeted for the year,” she warns.

How insurers could be impacted

SOLIC Capital’s Annas suggests the impact to insurers is mixed—and uneven.

“We’re seeing more providers target individuals with the higher deductible plans, which has become more common with the passing of the ACA,” he says.

This article originally appeared at Healthcare Dive on Feb. 29, 2016.

Following news Massachusetts General Hospital will open a concierge practice in August that will charge patients $6,000 per year for exclusive service, the concept is gaining attention.

Supporters suggest it’s a smart way for hospitals to draw more revenue, while detractors argue it creates a tiered system of healthcare that favors the rich.

While hospital concierge care isn’t new, as some hospitals have had programs for years, the time might be right for a boom in programs due to the growing culture of customer-driven healthcare and the influence of Mass General, whose backing of the trend may carry significant weight thanks to its 200+ year reputation for caring for the poor and its ongoing position as a No. 1 hospital in numerous categories ranked by U.S. News & World Report.

Several healthcare experts weighed in with Healthcare Dive on the pros and cons, and whether they predict a trend. They suggest the main issues hospitals face are determining whether concierge care is an appropriate fit for their unique circumstances, and managing any perceived unfairness.

Greg Charleston, CTP, CFA, CPA, Senior Managing Director of Conway MacKenzie Inc. and leader of the firm’s Healthcare Advisory Services Group

“I think hospitals will continue to develop higher margin value added services. They will likely be out-of-pocket items not covered by Medicare or Medicaid. These types of services can drive improved profitability. The downside may be the perceived unfairness between the quality of treatment by the ‘haves’ vs. the basic care for the ‘have nots.’”

John D’Andrea, Drinker Biddle managing partner and vice chair of the firm’s Healthcare Group

“I do think other hospitals are likely to follow suit.  Many have already gone there.

While the concept of concierge healthcare services seems inconsistent with the health reform movement and the charitable missions of many tax-exempt hospitals, there continues to be demand, often in large city markets, where high-earner consumers are willing to pay for a concierge level of service.

Hospitals will naturally want to compete for this business. They will need to reconcile this business objective with their charitable purposes, which typically include making high-quality, low-cost care available to the broader communities they serve.”

Jeff Hoffman, senior partner and health care strategist in management consulting group Kurt Salmon’s Health Care Group

“Concierge care isn’t necessarily an inappropriate fit for hospitals. But there’s not much rationale for its broad adoption. At the end of the day, even if 1,000 people sign up, that’s only $6 million. For hospitals in general, that’s not going to outweigh the potential negative publicity of appearing to create a two-tiered system. This will not be a big deal in the scheme of any hospital’s financial success or failure.

This is a strategy that has been around for 20 years and has not made any broad in-roads for hospitals across the country… efforts to reduce the overall costs of health care are taking root, and we’re moving toward telehealth and broader roles for nurse practitioners and other non-physicians in patient care. Concierge members may soon be paying for services and access that will be made redundant by telehealth and other technologies.

Because many hospitals are 501c3s, they’re not paying taxes. But if you start creating two tiers of medicine, you start chipping away at your argument that you’re a charitable institution.

If a hospital has to make doctors available on demand, those doctors can’t have a full practice and see as many patients. That’s a lot of wasted efficiency. Hospitals must weigh whether the inefficiencies inherent in catering to a small population outweigh the benefits.”

Bob Teague, MD, Quorum Health Resources’ vice president of medical transformation

“As hospitals seek alternative sources of revenue, this offering may increase in the market.  Systems with strong brand awareness and reputation like Brigham and Women’s are more likely to be successful selling this ‘fee-for-care’ service, as they can command a premium price and attract a sufficiently large private pay patient base to fill physician practices.

It is difficult for physicians who take Medicare patients to offer concierge services, since Medicare only allows physicians to charge a ‘fee for extra care’ for concierge services that are not available from Medicare. With the additional primary care-oriented services now reimbursed by Medicare (transitional care, wellness visits, and chronic care management), it may be increasingly difficult to meet this standard. And most hospital-employed physicians are likely seeing Medicare patients.”

Traci Bild, founder and CEO of national healthcare consulting firm Bild & Company

“Healthcare typically is not service driven; I do not think other hospitals will follow suit. They may envy Massachusetts General and even attempt to model them but facilitating this type of transformation requires tremendous leadership and accountability to results. In a chaotic environment grappling with tremendous change (with readmissions being a top priority), I think it’s at least five to 10 years out before we really see this type of change in the hospital environment.”

Andre L. Lee, DPA, FACHE, adjunct faculty member at Kaplan University School of Health Sciences and former hospital CEO  

“On the whole, I do not see this as a natural outgrowth of the majority of hospital services because it is not something that is typically covered by insurance carriers. It is, however, a very nice deluxe program that seeks to meet every conceivable medical and comfort desire of a patient. Some might even call it the top of the medical food chain, setting a standard that we wish everyone could have.

I do not consider it inappropriate at all. No matter what product or service you can conceive in this country, we always have one portion that is above average if you can afford it. That could be watches to pizza to barber shops; there is inevitably one more level above average.

Despite the emotional appeal in health care to help everyone in every way possible, it is still a business. As long as the core mission of an organization remains in place to try and meet the needs of the community, then having a choice of services is a part of doing business.”

This article originally appeared at Healthcare Dive on March 7, 2016.

While there is little apparent information on the incidence of physician impersonation, the issue periodically rears its head in the media, as in February, when news came out that a Florida eighteen-year-old was caught operating an illegal medical office.

That case emerged after the teen had allegedly operated a prior illegal medical practice in October 2015, and before that, posed as a doctor at Florida’s St. Mary’s Medical Center for a month in January 2015. The teen, Malachi Love-Robinson, was arrested after continuing to practice unlicensed medicine at his second clinic despite receiving cease-and-desist orders. He had not been charged over the St. Mary’s incident because he did not actually treat any hospital patients, though he interacted with them and was said to have “peeked in” on gynecology exams.

While infrequent, it does happen

Certainly, impersonation does not appear to be a common form of healthcare fraud. According to a late January report from the U.S. Government and Accountability Office, impersonation didn’t even make the list for the year studied.

“We didn’t find any examples of physician impersonation in the cases we reviewed for 2010,” GAO spokesperson Kathleen King told Healthcare Dive. “To my knowledge, no one else has reviewed fraud cases in other years, so I can’t say whether there have been other cases.”

That report notes the most common forms healthcare fraud to be fraudulent billing, billing for services that were not medically necessary, falsification of records to support fraud schemes, kickbacks to participants in fraud schemes, and fraudulently obtaining controlled substances or misbranding prescription drugs.

Anecdotal cases of impersonation, however, do appear periodically in the news. For one example, the Huffington Post hosts a “Fake Doctor” subject page with eleven articles that date back to 2011.

Why does it occur?

Some fakes reportedly operate independently from home or from offices they rent, or pose as home-visit physicians. While those cases are certainly disturbing, those that are perhaps the most startling are the ones involving fake physicians who manage to practice out of legit clinics and hospitals. Those are the ones that reveal the holes in organizational security and the complacency of employees who assume they belong.

Another major variable is motive; while many fakes appear to be driven by money, others may be after the experience regardless of whether they get on a payroll or bill patients, as when Love-Robinson flitted around at St. Mary’s. Other reasons could run the gamut and may not be readily apparent.

There are a variety of ways in which fakes infiltrate institutions. One way is by stealing another physician’s identity—particularly the identity of a physician with the same name, as in two California cases in which men named Keith Barton and Gerald Barnes each masqueraded as same-named physicians.

Another way is through the use of fake medical degrees offered online, which reportedly range from outright forgeries of degrees from recognized institutions, to those from fake or quasi-real universities. Some who use such sites may argue, and perhaps even believe, they earned the right to call themselves MDs or PhDs. Florida teen Love-Robinson claimed he received a PhD from a California-based university that he attended online and also claimed certification from several alternative medical organizations.

According to Degree Mills: The Billion-Dollar Industry That Has Sold Over a Million Fake Diplomas, published by Prometheus Books in 2012, “Fake medical degrees are an urgent problem. It is easy to buy a medical degree from a fake school, or a counterfeit diploma in the name of a real school.”

Check yourself before you wreck yourself

Sometimes, none of that may even be necessary if institutions fail to check credentials, perhaps relying on a candidate’s word, reputation, or the idea that they must have had credentials to have achieved whatever position they held previously. One of the most high-profile such cases involves a Michigan man who claimed to be a physician for 15 years, and was caught in 2010 when someone finally checked his credentials while he was serving as medical director for the medical simulation and research program at Beaumont Hospital in Royal Oak. He is said to have secured millions of dollars in research grants, fees, and salaries for performing research and training but did so without performing patient care, which is perhaps how he avoided scrutiny for so long–and perhaps how he avoided being regarded as a physician impersonator in the GAO’s report on 2010 healthcare fraud.

While fraudsters operating independently are a matter of buyer-beware for patients, the fact that some continue to make their way into institutions, whether to act in a formal capacity or simply circulate unimpeded, is a stark reminder to healthcare institutions to beware as well.

This article originally appeared at Healthcare Dive on July 19, 2016.

This article originally appeared at Healthcare Dive on Feb. 3, 2016.

Following the recently expanded guidelines from the U.S. Preventive Services Task Force, which now recommends depression screening for all U.S. adults over the age of 18 as part of routine healthcare, including for pregnant and postpartum women, several experts told Healthcare Dive they agreed it was time.

Whether the recommendation will have much practical impact, such as spurring further integration of behavioral health with primary care, remains to be seen.

Pete Mumma, the system director of psychiatry and behavioral health at LifeBridge Health in Baltimore, Maryland, says it’s something he’s been advocating for the last decade. He works closely with the system’s population health department and notes that symptoms of depression—even if they aren’t severe enough to reach the threshold for a formal depression diagnosis—can still create barriers for a patient’s functionality and effective management of their other medical conditions.

“The presence of co-morbid symptoms of depression and other mental illness very much impact that patient’s wellness,” Mumma says. For example, depressive symptoms such as lack of concentration and motivation can make it difficult for a patient to adhere to a drug regimen.

He concedes primary care physicians have previously had good reasons not to take it on: lack of time, given the average medical visit is already too short at seven minutes; and lack of referrals or resources to do anything about the results.

“That’s a very real concern,” Mumma says, “because there are access issues to psychiatric care in almost every part of the country.”

Despite that issue, however, Mumma argues that a simple screening for depression is very much akin to another vital sign.

“We need to identify what each person’s challenges are that prevent them from optimal wellness, and whether we screen for depression or don’t screen for depression, it’s still there in the patient,” he says. “In order to treat the whole patient we need all the information.”

As for whether the recommendation will spur behavioral and medical care providers to work more closely, Mumma says, “I think that’s happening already but I think it will drive a greater degree of integration.”

To help ease the screening process, Mumma promotes the practice of handing patients a tablet so they can privately enter their responses directly into their medical record. That can reduce the stigma patients feel compared to handing forms to staff, and it takes the burden off staff to find time to administer it or to address the subject during that visit.

Mumma adds that payer restrictions are the other major challenge because there’s no empirical test for depression. He hopes that by effectively mandating screening as best practice, depression treatment will become more broadly accepted.

Similarly, Dr. Nishendu M. Vasavada, a board-certified psychiatrist at Oceans Behavioral Hospital Plano and a distinguished life fellow of the American Psychiatric Association, says the recommendation has been overdue for the last 37 years—since the availability of screening tools. “Routine screening for depressive symptoms is appropriate and, frankly, it’s just the right thing to do,” he says.

He also believes the recommendation should prompt further steps toward the integration of behavioral and primary health. “Patients with psychiatric diagnoses are higher utilizers of medical care and often have poorer prognoses,” he says. “Ultimately, treating depression saves lives and money. The real cost of depression is from overutilization of medical services and loss of productivity, not to mention the cost to family life and risk of substance use.”

A supporter from the primary care side is Dr. Harold Sirota, DO  FACOFP, chairman of the Department of Primary Care at Touro College of Medicine in New York.

He also considers the recommendations late in coming, and notes that many primary care physicians have already implemented depression screening in their practices.

He sees insurance issues as the biggest barriers, from a lack of psychiatrists or behavioral health specialists available in patients’ provider networks, to a lack of reimbursement for the diagnosis of depression.

“With other diagnoses such as chest pain, a PCP can do the appropriate work-up, make referrals to a cardiologist and get reimbursed. With depression, this is not the case,” Sirota says.

“What is important is that depression exists, it is far more prevalent than previously realized, and we have a responsibility as PCPs to deliver quality care to our patients.”

This article originally appeared at Healthcare Dive on Feb. 17, 2016.

As multiple major insurers suggest they might leave the federal and state exchanges if they continue to lose money on their ACA business in 2016, the question is whether they are likely to make good on the threats or are more likely aiming to pressure the federal government into making the marketplace and its requirements more favorable for insurers’ long-term participation.

Another factor could come into play in Florida, where the state’s office of insurance regulation is supporting Aetna’s pending acquisition of Humana only on the condition that Aetna grow its participation in the state insurance exchange, which would prevent the company from potentially opting out.

Here is what several health insurance experts tell Healthcare Dive:

Deborah Dorman-Rodriguez, leader of the healthcare practice group at Freeborn & Peters LLP in Chicago and former chief legal officer of Health Care Services Corp.

“Insurers could end up leaving the health insurance exchange marketplace if they are unable make it work without sustaining significant financial losses, so the threats to leave the marketplace are not idle ones,” she says.

“However, managing the risks of populations insured through the various marketplaces is still new to insurers and they will continue to learn and improve on doing that. If a large number of insurers were to withdraw from the exchange marketplace it could be a detrimental to consumers in terms of limiting their choices of insurance products. If withdrawal from the marketplaces happens it remains to be seen what smaller insurers or new entrants would emerge and whether they will be successful.”

Duane Harrington, managing director and leader of consulting firm AArete’s healthcare practice  

Harrington suggests insurers will look at their performance in each of the states in which they operate, and any decisions to exit certain markets will have varied levels of impact.

“Broadly speaking, a variety of plans have been offered in the marketplace including those from Blue Cross-affiliated insurers, Medicaid insurers, provider-sponsored insurers, local or regional plans as well as those with a national footprint. Nationally, it looks like a good mix for competition, but it’s within the individual markets where the profits or losses are incurred, and where the impact of the exit of an insurer should be measured. That stated, there are insurers that are operating within the exchanges profitably, and where there are profits, insurers will find a way into those markets.”

Harry Nelson, founding partner of healthcare law firm Nelson Hardiman

Nelson suggests some insurers, such as UnitedHealth, appear to be mapping out a future without the exchange population, while others, such as the Blues, are likely committed.

“The exit of multiple insurers who had previously had a broad presence on the exchanges would be a major setback for the ACA vision and for the Obama administration,” he says. “The government is counting on the insurers to offer sufficient choices for consumers to make the exchanges viable… While a small number of insurer exits isn’t going to make a difference and while smaller regional insurers might fill some voids, it would be a bad indicator for long-term viability if a critical mass of insurers exited the exchanges.”

Darryl S. Weiman, MD, JD, author of Medical Malpractice and the Law

“If the big insurance companies pull out of the exchanges, it is unlikely that the smaller companies will be able to pick up the extra patients,” he says, adding if the government has to supply more support for premiums, healthcare costs will continue upward. “It is also likely that the quality of the health insurance will decrease since the people will have fewer options due to less competition,” he says.