February 23, 2014

Who Should Be in Charge of Medical Care?

This could be the $64 billion dollar question. I have been reading several blogs lately and each one seems to want to go in a different direction. Insurers are beginning to feel that they should have management control over health care. Doctors are beginning to push back demanding that they be in control. More patients are saying, “Now wait a minute, we would appreciate some voice in our treatment.” All of this may be out the window with government voicing more from the Centers for Medicare and Medicaid Services (CMS). They may drown out the other voices as they dictate more in what will be allowed and not allowed.

For many, having CMS wag the reimbursement tail and the insurance industry following lock-step will mean that neither doctors nor patients may have much hope of managing health care decisions. This may not be a good situation when insurers refuse to allow life saving procedures.

It was with some amusement that I read this by Dr. Pelzman in MedPage Today. Dr. Pelzman says, “A couple of years ago one of the major insurers got in touch with our practice and told us that they would like to come over to our office for a sit down, to talk about our patients and how we take care of them. When they arrived, the executive and his retinue of employees presented us with data that suggested that "we" were costing "them" a lot of money to take care of "their" patients. We went over the data they had, which showed it was costing them several million dollars more per year to take care of the panel of patients we shared than they collected in premiums from those patients.

Despite the fact that it appeared that much of the cost was due to several patients with acute leukemia who had massive unavoidable costs, they firmly came down with the recommendation that we find ways to take care of their patients with less cost.”

What follows is not a surprise as insurers want to make a profit and will take measures to ensure a profit. It is obvious that the practice Dr. Pelzman is part of felt they had to allow the insurer to install a care coordinator in their practice, even if this meant doing some practices that would literally exclude people based on their insurance status.

As patients, even we know the insurers have a purely financial interest in delivering care more efficiently and cheaply to patients. Then Dr. Pelzman goes where many doctors fear to go and says, “We should welcome the insurers to the table, as we continue building the patient-centered medical home, but it's time we as practitioners and providers of care seize the reins, take control, and start making some rules of our own. We are here to provide care for "their" patients, and ultimately we (hopefully) know best. We understand that they're worried about fraud, over-spending, over-testing, over-referring, but hopefully we can work together to build a more patient-centered way of taking care of these patients as our healthcare model changes in the 21st-century.”

Now if he had urged bringing the patients into the discussion and making them part of the decision process, then the doctors and patients would have had more bargaining clout for dealing with the insurers. Yet most doctors refuse to consider patients as having any advantage other than providing them income in the practice of medicine.  Too often, we are thought of as non-adherent and incapable of following their ill thought-out instructions.

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