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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