Stanley Feld M.D.,FACP,MACE
In our dysfunctional healthcare system tensions are building to great heights between the insurance industry, patients and physicians. The appearance of this article makes me think that the insurance industry subconsciously has a death wish to completely destroy the Healthcare system. The insurance industry is totally insensitive to patients and physicians. Its only concern is its bottom line and seducing employers to buy its product.
The healthcare insurance industry truly believes it owns the healthcare system and can push anyone around. It can force people to do anything it wants. I do not believe this bullying can last.
“After 26 years of a successful medical practice, Alan Berkenwald took for granted that he had a good reputation. But last month he was told he didn’t measure up — by a new computerized rating system.
A patient said an insurance company had added $10 to the cost of seeing Berkenwald instead of other physicians in his western Massachusetts town because the system had demoted him to its Tier 2 for quality.
“Who did you kill?” the man asked sardonically, Berkenwald recalled.”
No one notified Dr Berkenwald about his demotion to a Tier 2 doctor. You will also note that none of the insurance executives have taken a cut in their salaries. However, they feel compelled to cut costs, to keep the health insurance premiums down.
“In the quest to control spiraling costs, insurance companies and employers are looking more closely than ever at how physicians perform, using computers, mountains of health claims and billing data and sophisticated software. Such data-driven surveillance offers the prospect of using incentives to steer patients to care that is both effective and sensibly priced.”
You might recall the surveillance Blue Cross Blue Shield used on Dr. Petak. They made him a second tier physician because he used a medication that helped patients become pregnant without the use of expensive invitro fertilization. The fact is Dr. Petak saved the insurance company tens of thousands of dollars. So much said for automatic surveillance.
Why can’t the health insurance industry learn to use some common sense? The answer is they do not have to.
“It also raises questions about the line between responsible oversight and outright meddling in the relationship between caregivers and their patients. And it shows how people such as Berkenwald are at risk of losing control of their reputations as corporations and other organizations mine electronic data to draw conclusions about them and post them online.”
This is especially true when the criteria they use to judge performance might be faulty and have nothing to do with that physician’s clinical outcomes. There should be some serious consequences to the healthcare insurance industry. The interesting thing is the power to regulate the healthcare insurance industry belongs to the individual states. The state insurance board gives permits to the healthcare insurance companies to sell insurance in each state. It would be interesting if we had some local leadership exert its authority.
“The trend is in its infancy, but such programs are already in more than 100 insurance industry markets or regions across the country, from entire states such as Massachusetts to metropolitan areas such as Los Angeles.”
If the insurance industry can get away with the insanity, why not? It will increase the healthcare insurance industry’s bottom line. It will also result in a reduced payout in fees to physicians. Worst of all it will result in a decrease in medical care to the patients.
” Supporters say the programs have slowed the rate of growth of insurance premiums by 3 to 6 percent in their first year.”
I would like to see the statistical evidence for this minimal decrease in insurance premium growth. I would like to see the absolute dollars saved. I would like to see the reduction in premium. I would like to see if insurance executives’ salaries have decreased also.
Arnold Milstein, chief physician for Mercer Health and Benefits, a health-care consulting firm based in New York, whose firm is analyzing data for the Massachusetts program that ranks physicians said:
“In every industry, consumers have a thirst for performance information, “People don’t want to go to a movie or buy a book or buy a car or go to a restaurant without some ability to assess value for dollar. What’s taking place here is inevitable.”
Dr. Milstein is gathering data for the insurance industry’s benefit and not for the patients’ benefit. The information gatherers do not even have the meaning of quality medical care defined accurately. These consulting companies also make multiple collection errors because of their lack of understanding of the therapeutic contract (patient-physician relationship) and the analysis of inaccurate information.
“Physicians who have been profiled, including those with top ratings, say that the data often contain errors and that doctors often lack the ability to correct them. The effort is more about cutting costs than raising quality, some say, adding that doctors could begin to “cherry pick” healthier patients whose problems are less costly to treat. Such systems fail to capture the intangibles of quality, such as a doctor who visits a dying patient at home, critics say.”
In my view this is absolutely the wrong way to go about fixing the healthcare system. It is the way to destroy and demoralize the physician work force. It is a way of depleting a talented pool of physicians developed through years training. It is a great way of producing a physician shortage. It is a way for the healthcare insurance industry to make the physician community never trust you and never want to cooperate with you. At this moment in history cooperation is essential.
This is the reason I have been advocating consumer driven healthcare. The healthcare insurance industry has little concern for our well being. Its concern is for its bottom line.
It is especially clear that the healthcare insurance companies do not understand the value of the therapeutic contract (patient-physician relationship). Physicians and physicians’ organizations would like to ignore all this noise. They have better work to do. Their work is taking care of patients who are sick. However, we can not ignore this insanity any longer.
The information about quality has to be collected accurately. If a physician is not practicing quality medicine he should be taught how to improve by his peers and not punished by a third party with an unusual agenda.
As I stated, quality is not defined by how many tests you do but by your clinical outcomes. A recent NEJM article reported the British healthcare system is going broke by rewarding quality improvement measures. Clinical outcomes have not improved significantly.
“Doctors are rated on standards of quality of care and cost efficiency. An internist, for example, gets higher ratings on quality if he puts his heart attack patients on beta blockers, a medicine that reduces the workload on the heart, or if diabetic patients are tested for blood-sugar control.”
Just imagine the worst physician in a community figuring out what tests would give him a high rating and increase his income. He does the required tests routinely whether the patient needs them or not. He misinterprets those tests to the detriment of the patient. Yet he is rated the best doctor in the town. It is like a bizarre Fellini movie
The healthcare insurance industry is doing absolutely the wrong thing to improve the healthcare system. It thinks it owns the healthcare system. Their consultants do not practice medicine. They believe they understand the principles of good medical care. They also believe they can measure quality medical care and penalize physicians who do not adhere to their rules. Unfortunately, they are wrong. Unfortunately, patients will suffer.
The only stakeholder that will fix this system will be patients and not the healthcare care insurers.