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Time Not Well Spent: How Health Insurance Keeps Doctors From Patients

By Steve Simmons, M.D.

Last week, my partner wrote about a game played between doctors and insurance companies. After reading his post, I recalled the time I first learned that modern medicine was something altogether different than what I had expected. I began my career as a primary care physician in 1996.  Fresh out of residency, I was optimistic, naïve, and unaware that a very real game was being played. As time passed, I became a player in this game, but slowly realized that something of value was lost by my patients trying to translate their insurance coverage into health care.  Likewise, the struggle to interpret the healthcare system for my patients caused me the same frustration that has led many doctors to leave primary care today.

Early in my practice I was eager to begin my career, relieved that my training was over.  However, my training in the game had just begun. To my consternation, insurance company demands soon usurped the time I spent on everyday clinical problems. Often, I’d find my office stacked deep with charts waiting for my review and approval, a consequence of an insurance company changing a drug formulary involving dozens of patients. It seemed a day couldn’t pass without administrative staff requiring an explanation for a treatment I had already recommended so they could arrange pre-authorization.

Insurance coding was not taught in medical school or residency, yet it’s the primary language used to communicate with insurance companies. I needed to learn this ‘skill’ on the fly, using a code book to translate each medical diagnosis into a five digit number, with an additional number serving as a cipher to explain the type of work I had done for a patient.  This code book does not contain some diagnoses and many of its diagnostic codes inaccurately describe medical conditions, causing inevitable mistakes that led to non-payment.

In Money-Driven Medicine, Maggie Mahar describes the 1990s as the time of HMOs, when reimbursement became paradoxical. Then, an HMO gave a primary care physician $10 a month per patient, regardless of what we did or did not do for that patient. If we saw our patient in the office we kept the co-pay, but nothing else was reimbursed.  If we admitted a patient to the hospital, we received $0, resulting in lost office time, lost opportunities to see other patients, and lost revenue.

Some wonder why primary care physicians don’t go to the hospital anymore. Here’s why:  They can’t afford to leave the office.  They must stay put and move people through their office, which resembles an assembly line, if they want to stay financially afloat. When I observed that the only way to earn money caring for someone in an HMO was to never see them, my partner looked at an older colleague, smiled, and said, “He finally got it.”

Navigating nonsensical limits and rules became infuriating.  One young man, brought to me by his tearful father, was hearing voices. Soon into my exam I realized he suffered from a mental illness. His plan stipulated the patient only could initiate mental health benefits, not a family member. However, the voice was telling him not to call; yet he agreed to see a psychiatrist if someone else would call. I spent well over an hour pre-authorizing his mental health benefit.

Examples include physical illnesses too. I diagnosed a cancer in a woman whose HMO offered only one specialist; someone I would not have consulted. With no choice, I referred her. Days later, she returned in tears stating that she would never see someone who knew less about her problem than she did. I agreed and spent the rest of the afternoon wrangling with her insurer to get a different specialist approved.

When I moved to the Washington DC area, I left primary care.  For ten years I worked in urgent care, earning a steady paycheck while avoiding overhead expenses. I could go home without being followed by the constant frustration of trying to untangle impossible knots.  Yet, I missed the opportunity to build relationships with my patients and was not using the skills I had developed. When given the chance to work in primary care again without the endless hassles, I seized it.  Today, I am gratified to have returned to my calling. It is more rewarding to practice medicine outside of the current insurance model and I remain thankful to my partner at doctokr Family Medicine for the opportunity to do so.

Today, much is lost between patients and doctors.  If physicians and patients could connect without so many distractions, primary care would, again, resemble a calling more than a job and the primary care shortage would not be reaching a crisis point. Too much time and effort is spent on a game controlled by endless rules and regulations; time that could be focused on the patient — who should be the true focus, after all.

Until next week, I remain yours in primary care,

Steve Simmons, MD

Sneaky Things That Doctors Do To Survive Financially – Introduction

Dr. Val’s note: My friend and co-blogger Alan Dappen is going to prepare a series of posts to expose the convoluted billing and procedural tactics that primary care physicians adopt to survive the ever decreasing reimbursements that would otherwise put them out of business. Below is his introductory post – others will follow each Wednesday morning here at Better Health. Enjoy!

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The Doctor’s Huddle

By Alan Dappen, M.D.

On the great gridiron of healthcare, the team of primary care providers is leaning inward, supportively embracing one another.  They have huddled together for 15 years, calling plays against their opponent, the Insurance Team.  The two-minute warning has sounded and the Physician Team is losing. The Physician’s play book pieces together strategies culled from cocktail party conversations, doctor conventions, office staff meetings, back hallways of hospitals, online blogs, and a plethora of practice management magazines; routinely circulated offering grand strategies to teaching doctors how to tackle the Insurance Team. The rising mantra is “Hit them again! Harder! HARDER!”

This game began in the 1980s, when concerns that rapidly inflating healthcare costs would consume all the U.S. gross national product within the foreseeable future unless something was done.  Insurance companies lobbied regulators and advertised to the public not to socialize healthcare. Most people sighed relief when laws were passed granting insurance companies broad powers to regulate the price of care.  Little did these politicians realize that they inadvertently were “socializing” care by handing the keys to the health care gold mine to Team Insurance’s privatized, for-profit model.

Up until this point, the healthcare system had experienced 40 years of run-away costs. Patients with insurance hadn’t worried about the costs of care. Inside of this cash rich environment, many important innovations occurred but employers, who subsidized most of the cost, questioned the sustainability of paying for it.  All the while, physicians, hospitals, pharmaceutical companies, and medical suppliers eagerly reassured the patients:  “Since you aren’t worried about the price, then no one else should worry about it either. We’ll pass the bill to the insurance company–they pay what we ask.”

This modus operandi came to a screeching halt in the late ‘80s, when the aforementioned game began, and Team Insurance was allowed to fix prices via preferred provider contracts. Insurance providers understood that the key to these contracts was not to change the rules for patients, who needed to perceive their care as virtually free so that they would continue to seek care.

Instead, Team Insurance spelled out new game rules in contracts for physicians, where the physicians “negotiated” to accept roughly 50% of their customary rate in order to be listed in the insurance company’s Preferred Provider Directories. These rules were never acceptable to physicians. Docs refusing to sign contracts rudely were awakened by the new world order when 95% of their trusted clients refused to return until they could say, “Yes we are preferred providers.” And, “Yes, all you have to pay us is your co-pay.”

Patient expectations remained unchanged. Quality of service, patience, time to explain oneself, attention to wellness, review of multiple issues, meaningful personal relationships, prescriptions, detailed explanations of risks and benefits of treatments, reviews of other possible ideas in a differential diagnosis,  labs, call backs with results, and introductions to specialists were never connected to a price for patients before. After all, haven’t physicians had spent 40 years reassuring patients, “Don’t worry your silly little head about the price.” This time the boomerang came right back at physicians who suddenly were demanded to deliver all the same service for half the price.

The power of “owning” the patient for a $20 co-pay is not lost upon the insurance team.  Every year, as they hand out new contracts, these insurance companies congratulate their preferred doctor players for their work, quality, and dedication and try to not rub in the following truth, “We own the doctor and we own the patient. Any doctor who dares not sign our next annual contract for less money will find themselves without patients. Remember, for the patient the big thing that counts is that you can say yes to the $20.00 co pay. Now sign on the dotted line.”

Every “negotiated” dollar saved from paying Team Physician means smiles all around for Team Insurance and their fans (shareholders.)  Price fixing initially did control costs, but only for about five years.  The U.S. now is back on the trajectory of health care pricing doubling every 7-10 years.

So what’s going on in those primary care huddles? The game plays are called out: “More work, less money, patient demands, protection from malpractice, keep smiling … Somehow we’re going to make somebody cough up our money …Hit them again harder!  Let’s do it!  On one, break.”

Up next, I’ll show you some of the plays physicians have put into place to survive. And why you the patient might feel like the football. Play along, with us. Hup one, Hup two, hike!

Until next time, I remain yours in primary care,

Alan Dappen, M.D.

Health Care Policy Summit Brings Together Unlikely Allies

Better Health’s policy writer, Gwen Mayes, caught wind of an interesting new conference being held tomorrow in Miami. She interviewed Ken Thorpe, Ph.D., one of the conference organizers, to get the scoop. You may listen to a podcast of their discussion or read the highlights below. I may get the chance to interview Billy Tauzin and Donna Shalala later on this week to get their take on healthcare reform initiatives likely to advance in 2009. Stay tuned…

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Mayes:  Tell us about the upcoming conference in Miami on January 28th called “America’s Agenda: Health Care Policy Summit Conversation.”

Thorpe:  The conference will start a conversation on the different elements of health care reform such as making health care more affordable and less expensive, finding ways to improve the quality of care and ways to expand coverage to the uninsured.  The conference is unique in that we’ve brought together a wide range of participants including government, labor, and industry for the discussion, many of whom have been combatants over this issue in the past.

Mayes:  Will there be other meetings?

Thorpe:  This is the first of several.  There will others in other parts of country over next several months.  President Obama and HHS Secretary Designee Tom Daschle have talked about engaging the public in the discussion this time around.  So part of this is an educational mission and part of it is to reach consensus among different groups that have not always agreed in the past.

Mayes:  What encourages you that these groups will be more likely to reach consensus now when they haven’t in the past?

Thorpe:  The main difference is that the cost of health care has gotten to the point that many businesses and most workers are finding it unaffordable.  In the past, most businesses felt that, left to their own devices, they could do a better job of controlling health costs by focusing on innovated approaches internally.  What we’ve found, despite our best efforts, working individually we haven’t done anything to control the growth of health care spending.    The problems go beyond the reach of any individual business or payer and we need to work collectively.

Mayes: How will health care reform remain a priority in this economy?

Thorpe:  The two go hand in hand.  As part of our ability to improve the economy we’re going we have to find a way to get health care costs down.  Spiraling costs are a major impediment to doing business and hiring workers.  To the extent we can find new ways to afford health care it will be good for business and workers.

Mayes:  Health information technology is also an important aspect.  What are the common stumbling blocks to moving forward?

Thorpe:  There are three issues we have to deal with.  First, we have to have a common set of standards for how the information flows between physicians and physicians, and with payers and hospitals.  What we call interoperability standards.   Second, we have to safeguard the information.  Finally, cost is the biggest challenge because most small physician practices of 3 or 4 physicians don’t have electronic record systems in place.  To put in a state-of-the-art system can cost $40,000 per physician and most cannot afford this expense.  I think the stimulus bill will provide funds to help with these costs.

Mayes:  There’s always growing interest in the patient’s role.  How will this be addressed?

Thorpe:  We have to find a better way to engage patients in doing better job of reducing weight, improving diet and those with chronic disease to follow their care plan they worked out with their physician.  We also want to make it more cost effective for patients to comply with the plan.  Patients who comply with health plans will have better outcomes at lower costs. 

Mayes:  Who’s on the agenda in Miami?

Thorpe:  It’s at the University of Miami so it will be hosted by President Donna Shalala who was Secretary of HHS under the Clinton administration so she is well versed on health policy.  Also attending is the head of PhRMA, Billy Tauzin, a former Congressman and former majority leader of the House, Dick Gephart.  There will be some lay people as well for a nice cross section of consumers, labor, providers, business and others.

Mayes:  How can people learn more about American’s Agenda and the conference?

Thorpe:  The executive director of American’s Agenda is Mark Blum.  He can be reached at 202-262-0700 or at America’s Agenda.org.

Health Insurers Create A New System To Limit Access To Expensive Radiology Tests

I just got notice from Blue Cross that they will be implementing a radiology management program for all advanced diagnostic imaging services starting in 2010.  The costs of advanced diagnostic imaging (such as CT, MRI, cardiac nuclear medicine) are rising 10-20% per year.

Radiology management companies are an attempt by insurance companies to slow that growth curve. What does that mean if you are a doctor?  Let me tell you how the program will operate.  Blue Cross calls it their Radiology Quality Initiative or RQI, not to be confused with PQRI.  Here are the details of their radiology benefit management initiative.

Q:  What are the requirements? Read more »

*This blog post was originally published at The Happy Hospitalist Blog*

The Friday Funny: “Preferred Providers”

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