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Why Pay For Performance Measures Should Also Apply To Health Insurance Companies

In a recent post entitled, “The Joys Of Health Insurance Bureaucracy” I described how it took me (a physician) over three months to get one common prescription filled through my new health insurance plan. Of note, I have still been unable to enroll in the prescription refill mail order service that saves my insurer money and (ostensibly) enhances my convenience. The prescription benefits manager (PBM) has lost three of my physician’s prescriptions sent to them by fax, and as a next step have emailed me instructions to complete an online form so that they have permission to contact my physician directly (to confirm the year’s refills). Unfortunately, page one of the form requires you to fill in your drug name and match it to their database’s list before you can continue to page two. For reasons I can’t understand, my common drug is not in their database. Therefore, I am unable to comply with my insurer’s wish that I enroll in mail order prescription refills. This will further delay receipt of my medication – and probably increase my cost as I will be penalized for not opting into the “preferred” mail order refill process.

Now, all of this is infuriating enough on its own, but the larger concern that I have is this: How many patients are not “compliant” with their medication regimen because of problems/delays with their health insurer or PBM? Physicians are being held accountable for their patients’ medication compliance rates, even receiving lower compensation for patients who don’t reach certain goals. This is called “pay-for-performance” and it’s meant to incentivize physicians to be more aggressive with patient follow up so that people stay healthier. But all the follow up in the world isn’t going to get patient X to take their medicine each day if their health insurer or PBM makes it impossible for them to get it in the first place. And shouldn’t there be consequences for such excessive red tape? Who is holding the insurers and PBMs accountable for their inefficiencies that prevent patients from getting their medicines in a timely manner?

Pay-for-performance assumes that physicians are the only healthcare influencers in the patient compliance cycle. I’ve learned that we only play a part in helping people stay on the best path for their health. Other key players can derail our best intentions, and it’s high time that we look at the poor performance of health insurers and PBMs as they often block (with intentional bureaucracy) our patients from getting the medicine they need. While insurers save money by having patients struggle to get their prescriptions filled, doctors are payed less when patients don’t take their medicines.

Not a great time to be a doctor or a patient… or both.

Can Physician De-Skilling Be Attributed To The Use Of EMRs?

Turns out there is an unintended consequence of many of the current efforts to standardize the way doctor’s practice medicine.  It is called de-skilling.  De-skilling can occur when physicians and other providers try to adapt to standardized, new ways of doing things.  Examples of such standardization include clinical based care guidelines, electronic medical records (EMRs), Pay for Performance (P4P), Patient Centered Medical Home (PCMH) requirements and so on.

Examples of physician de-skilling were revealed in a recent study which consisted of in-depth interviews with 78 primary care physicians regarding EMR use.  EMRs are all about standardization – what data is captured and recorded, how data is reported, how data is used, and so on.

Over the course of the interviews, physicians in the study described significant examples of de-skilling behavior.  Most indicated  that Read more »

*This blog post was originally published at Mind The Gap*

Why Are Some Physicians So Bad At Communicating With Their Patients?

“I don’t have the time…I don’t get reimbursed for that.”  This is an all too common refrain from primary care physicians and practice managers when ever the subject of improving physician-patient communications comes up.

I get it.   Primary care physicians in particular are under tremendous pressure to produce.   Just imagine…physicians in small primary care practices spend about 3.5 hours/week just on dealing with insurance-related paperwork.  Then there’s keeping up with recommended treatment guidelines, journals, and IT issues and routine staffing issues…not to mention routine patient care, much of which they in fact do not get paid for.  Physicians do have it rough right now.

But Doctors Can Sometimes Be Their Own Worst Enemies

Currently, in just about every State, Read more »

*This blog post was originally published at Mind The Gap*

More Bureaucracy: Quality Healthcare Measured With Check Boxes

With the news that Wellpoint, one of the largest insurance companies in America, will cut off annual 8% payment increases to about 1,500 hospitals if they fail to “test” high enough on 51 quality measures, they have officially defined “quality” health care as checkboxes.

Yep, checkboxes.

You see how do insurers know if we offer each of our patient’s nutritional guidance or exercise counseling?

Well, they check to see of doctors have clicked on a yellow warning box advising we do this. If we have, then not only is that doctor a fine, “quality” doctor, but the hospitals (and it’s computer system and scores of administrative staff that compile and submit this data) are real, fine, “quality” hospitals.

That’s all there is to it.

Never mind if we don’t have time to actually perform the counseling.

* click * * check * * click *

Simple as pie. Efficient, too.

Beautiful bureaucratic quality.

Good luck with that.

*This blog post was originally published at Dr. Wes*

Do Most Hospitals Have Similar Performance Scores?

Quality measures. Patient satisfaction surveys. With our new health care reform law, these “performance measures” are the new black in health care.

Hospitals are currently spending, conservatively, tens of millions of dollars to bolster these “performance measures” in hopes of securing a refund of a mere 1% of payments that CMS will soon withhold from them in the name of “assuring” quality improvement.

But what if, nationwide, there wasn’t a big difference in these measures between hospitals? What happens then? Might payments then be made on political grounds?

Performance measures have been collected for some time now in anticipation of this new payment initiative by the government, so data exist to evaluate. In fact, Kaiser Health News was nice enough to aggregate the findings from our government’s Hospital Compare website for my review.

So I calculated the mean, median and standard deviation of the results of all of this data collected across 50 states and 2 territories and found very little difference in measures collected between states: Read more »

*This blog post was originally published at Dr. Wes*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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