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Texas Medical Association Hits A Home Run


Stanley Feld M.D.,FACP,MACE

I have called for real price transparency from all the stakeholders. The healthcare insurance industry has stated that it will become more transparent. So far its pricing has been opaque. There are many levels of opacity to its pricing.

The Texas Medical Association (TMA) has taken a historic leadership position in defining what it thinks the healthcare insurance industry code of conduct should be in 2009. It is very complete. I hope it is adopted by the state of Texas and every other state in the nation. It will serve to lower the cost of healthcare insurance and increase the insurance coverage of many of our citizens.

“Health Insurance Code of Conduct 2009

“These measures would ensure transparency and accountability in the way health insurance companies conduct business:”

  • “Health Coverage Cancellations: Require an independent review of all decisions to cancel an individual health insurance policy prior to the actual cancellation.”

Each point in the TMA’s code of conduct peels off a level of price opacity. The TMA should call to abolish the healthcare insurance industry’s ability to cancel healthcare insurance.

  • “Calculation of Premium Quotes: Subject health insurers to “file and use” requirements at the Texas Department of Insurance (TDI), like other kinds of insurers.”

The Texas Department of Insurance (TDI) controls permits for the sale of insurance in the state of Texas. The TDI has never had the same pricing information from the healthcare insurance industry as they have from other insurance vehicles.

  • “Calculation of Medical Loss Ratio: Require health insurers disclose how they spend the patient’s premium dollar.”

The healthcare insurance company will not only have to disclose how they spend the patient’s premium dollar, they will have to prove it. This is an area in which expenses are inflated by the healthcare insurance industry.

  • “Unregulated Secondary Networks (Silent PPOs): Regulate how a physician’s contract information is sold, leased, or shared among health insurance companies.”

Unregulated secondary networks must be regulated because the healthcare insurance industry has long practiced price fixing. Price fixing does not work and leads to further system abuse and mistrust.

  • “Physician Rankings: Require health insurance companies to use scientifically valid criteria to evaluate physicians’ performance and disclose those criteria in advance.”

I do not believe physicians are afraid of being evaluated. I believe they are afraid of being judged by defective criteria leading to reimbursement penalties.

  • “Claims Processing: Prevent health insurance companies from reverting to their old, unethical ways of processing claims.”

I have pointed out abuses that have occurred in several states. Minimal monetary fines do not deter this abuse. It must be stopped. The healthcare insurance companies should lose their privileges to sell healthcare insurance in the state.

  • “Timely Health Insurance Information: TMA’s “Health Insurance Product Labeling Plan” would require health insurers and their brokers to use standardized reporting measures to help employers and individuals make direct, side-by-side product comparisons.
  • Once a plan has been selected, patients should have convenient access to benefit information when they are making their health care   decisions. Health insurers should make this information easily available. Almost every card in your wallet has some ability to provide data — except your health insurance card. There is absolutely no reason why health insurers cannot provide accurate, real-time information regarding the different benefits and exclusions.”

Buyers of healthcare insurance should have the ability to know the provisions of their insurance clearly and not be surprised by their lack of coverage when they get sick.

  • Routine Medical Care for Clinical Trials
    Texans participating in a clinical trial should be able to use their health insurance to pay for routine medical costs — especially when they are suffering from a life-threatening disease or condition.”

Many states have this provision. Texas does not. Patients have had to spend out of pocket expenses unexpectedly.

  • “ TDI needs authority to require health plans to disclose the methods and data they used to set “maximum allowable” amounts for out of network services.”

There is a tremendous burden place in our mobile society on citizens if they get sick while traveling for business or pleasure.

  • “TMA opposes health plans’ attempts to prohibit balance billing or to establish wholly inadequate payment rates for non-network physicians and hospitals.”

I disagree with the TMA balance billing position. We have to have total transparency from all stakeholders. I have maintained often that all stakeholders have to be subject to real price transparency including physicians

  • Regulation of Preferred Provider Organizations (PPOs)
    Currently the discounted rates physicians negotiate with health plans are being hijacked by unregulated PPOs. These entities, called “silent” and “rental” PPOs, shop around to find the lowest rate a physician has agreed to with any health plan. Then the PPO sells, resells, or leases that discounted rate to insurance companies, discount brokers, and other unregulated health care businesses without the physician’s knowledge or permission. Fourteen states outlaw these arrangements. Texas should, too.”

Few healthcare policy wonks know about this practice. It is a very effective practice by the healthcare insurance industry to create price controls. The results in further distortions in the healthcare system.

If the Texas legislature passes all these proposals it will make the state of Texas a more attractive state for large multinational corporations to set up corporate headquarters. Presently a powerful stimulus is our low tax rate.

I believe these proposals should be national for the benefit of all Americans. It will go a long way toward Repairing the Healthcare System.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

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