The Professional Patient Perspective
(This is a new, periodic column that discusses views on the healthcare system from the perspective of an industry professional who happens to be a patient with a chronic condition.)
Perhaps the biggest source of problems in this industry is the sheer number of different interests involved (i.e., patients, clinicians, hospitals, diagnostics, payers), and the differences in their perspectives. In other words, there are so many processes, experiences and stakeholders involved in providing care to one patient that we often can’t see the “big picture” from a different point of view.
One example from my own recent experience involves a chronic, severe sinus infection, my long-time ENT, and my high deductible/HSA health plan (offered by a large, extremely profitable payer). After three months of drugs and outpatient visits, my doc recommended an outpatient surgery procedure at a nearby surgery center to help clean out the problem. I thought this was a great idea, and the only other facility option for this doc besides this surgery center is a nearby hospital. (I have not had good outpatient experiences with that hospital so to me, it is not an attractive option.)
There are plenty of other people with health insurance similar to mine, and expectations are that many more will have this option as employers try to manage health insurance premium costs. Enrollment in high-deductible health plans paired with health savings accounts continued to grow between January 2010 and January 2011, from 10 million to 11.4 million members, according to the most recent census (June 2011) by AHIP.
I soon learned not all providers are willing to contract with this type of benefit plan, and in fact, the surgery center my doc suggested (and other similar facilities near me) will not contract with this benefit product. The reason they told me is that the high deductible amount sets up the provider, especially in the beginning of a benefit year, for a higher incidence of late or non-payment. And even if I wanted to come to their facility with a big bag of cash, their contracts with other plans from this same insurer prohibit them from treating me at all (unless I was to suddenly stop being a covered member in my plan).
I can totally understand where providers are coming from. Most HSA funding is deposited as wages are earned, up to the yearly total amount selected by the member. So in other words, you may have selected an annual HSA amount of $3,000, but on January 31st you will only have a fraction of that amount deposited in your account. And of course if I don’t have enough HSA dollars available to pay a bill, then I am looking for funds elsewhere.
Needless to say, this arrangement is not very beneficial to consumers who live in metropolitan areas where there are plenty of specialists and facilities. In such populated areas providers more often than not have the luxury of refusing to contract with whole carriers, and/or being highly selective of the types of plans they do accept. From my perspective my health plan isn’t very attractive, yet I am sure from the employer’s perspective it saves them a lot of premium dollars each year.
From the insurer’s perspective it is good business for their banking division, which holds and manages the HSA funds. Most of my docs do participate with this plan but are completely confused as to how to collect a co-pay, and I don’t blame them. Most of the time we are negotiating on what we think sounds good, as I regularly check my online account to see when the high deductible is met.
So what about the overall quality of care as perceived from the patient, doctor, and payer perspectives? In my case, I am rather miffed about not being able to receive the most timely care at a facility with a fairly open surgical schedule. But thankfully my issue is not urgent enough to require immediate surgical intervention. But if it was? Hey I have insurance – I should get the care that I need when I want it, right? It is easy for most insured patients to believe this and demand their choice of care. Perhaps if I didn’t work in the industry I would be more upset.
I found the following fact relevant and interesting:
A national mail survey of 627 doctors randomly selected from the American Medical Association Physician Masterfile showed that 42 percent believe patients in their own practice get too much medical care, while 52 percent think the amount of care is just right. (The study is published Sept. 26 in the Archives of Internal Medicine.)
But only 6 percent believe their patients receive too little care, the survey found. Many health care epidemiologists and economists have suggested that much U.S. health care is actually unnecessary, the study authors said.
Almost all said they believed that primary care physicians vary in patient testing and treatment, and three-quarters were interested in learning how their own practice compared to others.
Malpractice concerns drive many decisions to treat aggressively, the doctors said. More than 80 percent felt they could easily be sued for failing to order a test that was indicated, while 21 percent felt they could be sued for ordering a test that wasn’t. Having too little time with patients was cited by 40 percent as another reason for aggressive treatment.
So if there is this much variation in primary care treatment and testing, what will happen under Patient-Care Medical Home (PCMH) and ACO models? How to balance fear of lawsuit (and overtesting) versus being more accountable for treatment costs and outcomes? My sympathies for the primary care physician.
And what about physician views on payers? I read this Medscape article, “How Doctors Get More From Insurers (Despite Anger and Frustration)”. More than 10,000 physicians across the nation participated in Medscape’s Insurer Ratings Report 2011. Feelings of outrage, resignation, and powerlessness dominated the comments that we received. A noted theory by participants: If the companies can wear physicians down with repeated denials and paperwork demands, a high percentage of doctors will give up trying to secure their deserved reimbursement.
The highlights of the survey include:
- 28% of physicians say a Blue plan (Blue Cross, Blue Shield) is their best insurer, followed by Aetna, United Healthcare, and Cigna.
- 14% of physicians say United Healthcare is the worst insurer, followed by Blue plans, Aetna, Cigna, and Humana.
- Three in 10 doctors say they don’t know which insurer is their best payer.
Wow. Can’t we all just get along? The survey also discovered that many docs have no idea what the highest reimbursement is on their highest CPT code. So despite the fact that docs are clinicians and may not want to be involved at all with the business side of a practice, they really need to know a little more than they already do. There is a lot of industry talk about engaging patients on care options and costs. Maybe we can engage some other parties while we are at it.
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