As I have stated before payment for outpatient services would work better if divorced from the current insurance payment model. This CNN article nicely documents the significant hassles that our current insurance system adds to practicing physicians – Do insurers meddle in your medical care?
Dr. Yul Ejnes, an internist based in Cranston, R.I., said this example typifies how insurers are increasingly influencing how doctors practice medicine.
“There’s no question that payers are creating hassles and barriers to doctors,” said Ejnes. “There are so many rules for us that just make no sense.”
For example, Ejnes said Medicare covers a yearly prostate exam but won’t reimburse doctors for another service, such as a blood pressure check, that is done on the same patient on the same day.
Asked Ejnes, “Should I have the patient come back just to check his blood pressure so I can get paid for it?”
When health insurance started, it just covered surgery and hospitalizations. Two factors probably (please correct my history here) changed payment – Medicare and managed care. Managed care started with a focus on primary care. Thus, other insurers added primary care payments to their packages. Medicare started paying for outpatient visits, so other insurers followed.
I believe that the costs, both direct and indirect, of visit based insurance payment have had a major adverse impact on outpatient practice. As the article describes, our practices do not fit all the rules that come with insurance companies. Overhead does increase dramatically. We write extensive notes to justify billing levels, yet these are notes that contain unnecessary repetition. Such notes make chart review more difficult, searching for needles in the haystack of required systems review and physical examination.
The current system discourages physicians from spending adequate time with each patient. Rather, we make more money from volume than from time appropriateness.
As I have stated recently, I would like to see some combination of “cash-only” or retainer practice for the majority of outpatient generalist medicine. We have perverse incentives in our current system.
Changing models would lead to some unemployment for the staff we currently hire to deal with insurance companies and fill out arcane forms. We would, I believe, deliver much better health care. Our patients would benefit, and they would have increased respect for their physicians. We would have better communication, because we would have the time to communicate.
Chris Curran, spokesman for health insurer Cigna Corp. (CI, Fortune 500), disagrees with the idea that insurers are interfering with physicians.
“First of all, insurers don’t want to come between patients and doctors in terms of recommending care,” he said. “That’s the role of the doctor, not the insurer.”
At the same time, Curran agreed that insurers can add value to doctors and consumers.
“We are at the nexus of patient and doctor,” he said. “We have a role to play. We can help people understand their [health care] options and keep costs down for patients.”
“Look, consumers also need to know that it’s not guys like me who are making decisions,” Curran added. “We employ 3,000 clinicians at Cigna and they work with doctors to help them with the best care options.”
We should return those clinicians to the health care workforce. I have yet to have an insurance company clinician help me care for my patients. I have had the reverse.
The problem is the model. I believe the model cannot be fixed because it has such fundamental problems. We must embrace new models.
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Bravo! As I recall, the big run-up in costs for office visits started at the time insurance companies starting covering ov’s. We certainly do need a new business model! How it is to be implemented is another thing…
As was stated by the article Physicians are protecting the public as much as possible from the affects of health insurance meddling. Patients see it as annoying when the doctor prescribes a medication and then they go to the pharmacy and are told that it is not covered. What the patient does not see is the physician stopping what he is doing finding alternative and calling the pharmacy to be told that the other drug is not covered either, then we round robin through a bunch of medicines to find the one the insurance company is covering this quarter (they are constantly changing their formularies). Insurance companies are also constantly sending us requests for notes to prove that we did what we said we did (this means the doctor has to rereview the notes and have the staff send copies and rebill the insurance, a nice way for insurance to delay payment of the $25 by another few months (I am an internist in new york and here the insurance companies try to pay less than $40 for visit, the medicare rates look good over here).
The most disturbing thing was when my 7 year old daughters school asked for a physical and I took her to the pediatrician. A few weeks later I got a letter from the carrier saying they were not going to pay for the physical because I had to prove that there was no pre-existing condition. My daughter has no conditions, she is healthy and only needed a physical.
The insurance company representative has the gall to say that they don’t intefere in the physician-patient relationship?
Insurance companies are worthless. This month I got a stack of denials of checkups for routine asthma care and allergies on 18-22 year olds simply because the insurance companies now require college transcripts and proof of full time status to pay the claims. The insurance still collect the premiums. Other fun delay tactics, include verifying that a child under 18 does not have a different insurance plan, even though the child has had the same insurance for the last 5 years. Do not try to use back pain, leg pain, or hip pain as a code, as this creates an audit of the claim to make sure it is not a work comp claim. Most of the pain I see is from OA or working outside on the weekend.
I have to document the same things over and over in the office notes, with copays hitting $30-$35 for 09 and no increase in fees. Sometimes I feel like a scribe to work for the massive $15-$22 dollar check from the insurance company.
Insurance also try to deny claims for spouses of patients, wanting to make sure no other insurance exists. Mind you that the kids and spouses have plastic insurance cards that are worthless.
Outpatient visits should all be directly paid for with health savings accounts or insurance cards that can be run like a credit card. The best doctors would get the requested fees, and the poorly rated doctors would get lower office fees. This would represent an open market healthcare system. Patients could negotiate their MRI/CT prices and the benefits of brand versus generic drugs. Put the cost controls in the hands of the patients with a finite amount of money, and healthcare costs would decrease.
Currently the insurance companies have scared the population into not wanting any alternatives or changes. If the new public plan is adequate and designed similar to Medicare, millions of people will endorse the plan. This means a decrease in private insurance companies and a decrease in overpaid insurance company executives.
A new online news source, Concierge Medicine Today, is now available for physicians interested in this relatively new practice model. http://www.ConciergeMedicineToday.com