Knowledge is Healing

The answer to that question might depend upon a reading of state insurance law, whether a state has passed exemptions for religious organizations that pay for medical bills, or even the religious sensibilities of the parties involved.

Backers of these plans say they provide a low-cost alternative to insurance for people who otherwise couldn't get it or afford it. Their detractors say these plans are insurers in sheep's clothing, trying to find a way to shimmy out of state insurance financial and coverage regulations.

Either way, doctors might not know their patients might be participating in these bill-sharing plans, because often the plans are constructed so a physician is paid in cash first, after which the patient's bill is published in a plan's newsletter, with a request for reimbursement. However, sometimes physicians face the same wait for payment as they do for any health plan.

Christian bill-sharing plans aren't new, but have attracted more attention lately because of regulatory and legislative activity, and because the plans are being pitched as an alternative to not being insured -- though they say they're not insurance.

The Cover Florida health reform plan Gov. Charlie Crist signed in May included an amendment exempting faith-based health care programs from state insurance regulation, as long as the group qualifies under federal guidelines as a nonprofit religious organization.

Still, these hospitals continue to have a higher percentage of unpaid medical bills than physicians and nonprofit hospitals.

For-profit hospitals saw bad debt levels as a percentage of revenues fall from 18.4% in the fourth quarter of 2007 to 17.7% in the following quarter, said Fitch Ratings' recently released "For-Profit Hospital Industry Quarterly Diagnosis" report.

Past surveys by the Medical Group Management Assn. estimated physician practices' bad debt level in the 5% to 10% range. For nonprofit hospitals, Fitch said the percentage in 2006, the latest data available, was 5.5%. Bad debt is generally defined as payments that are written off as uncollectable.

Fitch analyst Lauren Coste attributes the decline in bad debt among for-profit hospitals in part to decreases in the number of uninsured patients at those facilities.

In addition, hospitals have been more aggressive in collecting co-payments up front and have improved efforts externally and internally to collect debt, she said.

This has balanced a change in for-profit hospitals' accounting techniques, Coste said. They have become more conservative in their assumptions concerning how many of their patients would pay for their services, which results in more debt being written off as uncollectable. Before, their accounting figures reflected a more hopeful collection amount.

A recent study by Cambridge, Mass.-based industry analyst Chilmark Research found that of the more than 200 PHRs on the market, only 20% are Internet-hosted, which is what the study focused on.

Of those, 40% are thriving, 35% are treading water "and the remaining 25% are walking zombies, not quite dead, but not very alive, either," the study said.

Study author John Moore said PHR vendors, until recently, were marketing to consumers. But with the exception of those with a chronic disease or their caregivers, consumers had expressed very little interest.

Now employers and health plans are starting to see the potential for PHRs to reduce health care costs, Moore said, and are offering incentives for their use. So vendors are focusing on strategic alliances.

Moore said privacy and security hurdles still need to be cleared before consumers can be sold on offering personal information for any PHR.

"What really surprised me [in doing the survey] is what a terrible job the PHR vendors have done addressing privacy and security as an industry," he said.

Moore believes the entrance of Google and Microsoft into the market could help raise the bar on what consumers will expect.

But the American Medical Association and others aren't waiting for vendors to respond, but would like to see legislation mandating security standards. The AMA is advocating that HIPAA be extended to all entities that have contact with health data, including PHR vendors.

On May 28, Aetna issued a list of commitments it said it would make as of June 2, when its five-year settlement with physicians and multiple medical societies expired. Aetna was one of numerous plans that settled lawsuits accusing them of developing schemes to underpay doctors, though the plans did not admit wrongdoing.

Aetna specifically committed to continue: allowing doctors to leave the network 90 days after giving notice; allowing claims submissions up to 120 days after the date of care; making its fee schedule available 90 days before any change; and contracting without all-products or gag clauses.

Aetna also promised to maintain its Physician Advisory Board, which advises the insurer on coding and reimbursement issues.

"I think it's pretty clear that most of this stuff is just good business practice," said Troyen Brennan, MD, MPH, Aetna's chief medical officer. "We've gotten beyond unhelpful adversarial relationships," he said. "We have every intention of maintaining those warm and collegial relationships."

North Carolina Medical Society Executive Vice President and CEO Robert W. Seligson is also president of the Physicians Advocacy Institute, which has overseen compliance with Aetna's settlement and others between health plans and doctors. He called Aetna's commitment to future cooperation with physicians a "model for other health plans."

Vanderbilt and the owner of 100 Oaks Mall are working together to transform a half-empty shell of what was once a vibrant shopping destination into a modern, state-of-the-art medical mall -- at half the cost of building a new complex. When completed, 16 medical clinics and support services will be housed on the second and third floors of the three-story building, and in an adjoining office tower. Restaurants and existing retail would remain on the first floor.

By making this move, Vanderbilt solves a space crunch at its main campus, which is landlocked and growing at a rate of 6% to 9% a year; provides larger, modern facilities for its clinics and easy access for patients; breathes new life into a deteriorating mall; and offers another alternative for physicians looking for new places to set up offices.

The project, called Vanderbilt Health at One Hundred Oaks, is still in the construction phase -- only the pediatric rehabilitation clinic has opened so far. But the concept is being watched, as experts in various fields imagine the possibilities any success could bring to other vacant retail spaces -- and to physicians who might be interested in filling them.

Millions of square footage in dying malls across the country could be revived. Boarded-up retail shops and grocery stores could become thriving tax-paying entities. But more important to many landlords is the fact that the glut of new retail space on the market could be filled by traffic-generating physician practices.

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