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Actuarial Design of Risk Pools


Posted by Dr No on 05 August 2010

firing_squad.jpgAmericans, Fanny Trollope observed in that acetic manner of hers, pursue the DOLLAR with such a unity of purpose, such a sympathy of feeling as found nowhere else, except, perhaps, in an ants' nest. “The result” she added “ is exactly what might be anticipated. This sordid object, for ever before their eyes, must inevitably produce a sordid tone of mind, and, worse still, it produces a seared and blunted conscience on all questions of probity.” To which we on Blighty’s shores might happily reply “Amen to that”, were it not that American ants’ nests have lately appeared with pestilential frequency in NHS offices up and down the land.

Dr No refers, of course, to the invasion of the NHS by the American for-profits health insurance giant UnitedHealth. UH now has more feet under NHS desks than a hydra has heads. Only last month, UH beat off BUPA and Humana to win a DoH contact to ‘support’ PCTs and of course in due course GP commissioners on their ‘commissioning capabilities’. Amongst the UH goodies on offer, PCTs can choose from:

• Practice based commissioning data tools for budget setting and actuarial design of risk pools and incentive overlays and facilitating consortia development to gain maximum benefits

• Profiling primary care performance, Medicines management and Skill mix redesign at the primary/secondary care interface

• Strategies for changing clinical practice including clinical decision support methods including Turnaround help with rapid development of plans

• Change programmes underpinned by tools that integrate silos of data into patient-centric information tools

Fanny, of course, would have spotted the DOLLAR in all of this straight away. For Dr No, who does not speak American, it took a bit longer, and a bit more probing on UN’s UK website. Nonetheless, it is all there, all in plain and easy language, if one is prepared to dig that bit deeper. Dr No particularly recommends – for those who want to brown their trousers in double quick time – the following four pdfs: HealthNumerics- AIV; HealthNumerics- EBM; HealthNumerics- RISC and HealthNumerics- eSync.

HealthNumerics-RISC, for example, assures us that UH technology ‘loads data from multiple sources’, determines admission risk, and then ‘ranks every patient from highest to lowest risk’, so providing ‘predicted costs for the next 12 months at individual patient and population level’. A helpful graphic reveals that a Henry Fordham, an 82 year old white Irish male, tops today’s high risk pops.

Just too bad if you rate as high risk, and are predicted to cost too much: for you, your care is over…

3 comments:

Worrying stuff Dr No!

I have read the four pdfs. It was interesting (in a Chinese sort of way) to read in Health-Numerics-AlV that its features include "Rules for coding errors - to identify inappropriate or incorrect coding or recording."

It appears these coding errors didn't - or did and were ignored - light up in the good old USA. See www://healthimaging.com where it states "UnitedHealth Group in a $50 million settlement.... said the industry engaged in "a scheme to defraud consumers" by systematically underpaying patients by hundreds of millions of dollars in the last decade...."

Also see www://amednews.com where it reports "Organised medicine struck a deep blow against unscrupulous insurance payment tactics more than a year ago when in helped to secure a $350 million settlement in a class-action lawsuit against UnitedHealth Group."

Despite the above, it appears that UnitedHealth Group are continuing to buy up and takeover other insurance groups in the US.

Did the NHS not do its homework?

God Forbid that we are on the road to total private healthcare and the need for health insurance, for if so read: www://drgrumpyinthehouse.blogspot.com. Yesterdays post "Things that make me grumpy" is an alarming warning of what is to come!

It is strange that very highly paid people cannot see it until its too late: so many banks and now the NHS. There are only so many doctors and the truth is there are only so many specialists: so what if the very rich (from oil not from work) wants to come and have the “specialist” treatment and the foundation hospitals can make money? Very few Consultants are saying much as either way they know they will have good income: there are only a limited number of operations you can do in 24 hours a day! Very scary.

That number crunching sounds scary, however this is a tangled story and if you're not aware of the seamier side of American medicine please check this out And that's just Florida.

The exasperating thing about it is the many of the folk we employ to run our NHS are idjits and have to get relatively non idjits in to do the jobs the idjits should be doing - doubling the costs and causing massive and morbid administrative constipation. An enema is indicated.

Bean counting yankees waving smart software as the cure for what's ailing the NHS is a delusion and I smell corruption... and a bunch of nitwit self regarding credulous fools at the helm.