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American Medicine: Information is Power
September 24, 2007
They have the goods on you. They know what you are doing, and you are not going to get away with it any longer. Pretty soon they are going to come after you and hit you where it hurts.
You see, information is power. You don’t know much about them, and they know a whole lot about you. They know the people with money and are padding their pockets through these connections.
I am talking, of course, about the insurance companies. They hold the healthcare system by the neck because of information. They know what things are being done in medical offices, hospitals, emergency rooms, and nursing homes. They have huge control over what doctors are paid, and can reduce rates without much possible recourse by the physicians.
Now they are starting to measure quality. They are part of the growing trend of "pay for performance," where physicians are "rewarded" for performing high-quality medicine. Obviously, the money for "bonuses" will come from somewhere. Will it come from the savings yielded from good care (less hospitalizations in CHF, Diabetes)? Or will it come from decreased pay for doctors not playing the game right?
The concept sounds appealing for those who understand just how malignant fee-for-service medicine is. I am paid less for spending time with my patients. I am paid less if I spend time ordering preventive medicine. I am paid less if I keep patients out of my office for unnecessary visits. I am paid less if I avoid expensive procedures. To be rewarded for these things sounds great.
But those who oppose pay-for-performance rightly point out the devil in the details. Just who is watching over the quality? Why, it is that group of people who lose money if they pay physicians more. They are the ones who determine your quality. Sure, just put the fox in charge of the hen-house. Great.
So why is it that the insurance companies are in charge of things? They are the only ones with the information. If the goal is to improve quality and decrease cost, and they are the only ones with information about both cost and what procedures are being done. That information gives them enormous power.
It doesn’t have to be that way. Physicians certainly know the cost of what they are doing; yet most physicians don’t have a means of demonstrating their quality. Most.
Whenever I get "quality reports" from insurance companies, I check them against our database. They are wrong as often as they are right. While that really is a scary thing when you consider the fact that physicians’ pay will depend on these numbers, it does demonstrate an opportunity for physicians to wrestle back control over the healthcare system. We can have better information than the insurance companies. I already do.
It would seem that physician data would be better than insurance data. The data of actual care are better than the secondary data from claims. Plus, physician data can be used proactively: to change behavior in the exam room. I can check and see if a patient is due for preventive care while I am with my patients. Isn’t that better than an insurance report?
Given these facts, I called the large insurance carrier in our area (with a name resembling indigo x), and made a proposal: "You give me all of your protocols for authorization of procedures, consults. I can put them into my EMR and keep them 100% of the time. You can audit us whenever you want to assure we are in compliance. In exchange, we don’t have to ever get an authorization and since you significantly cut your overhead, we get paid a little more."
What’s in it for them? They don’t have to pay people to authorize procedures and are assured of higher quality. What’s in it for us? We get paid more and never have to get authorizations. Plus, if Pay-for-performance takes off, we can use our own data and know it is correct.
Did they accept? Of course not. They would rather lose money than power.
Physicians turned power over to the insurance industry by letting them hold the information on us, but now have the chance to take it back. We just need to get the information. Remember, information is power.
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September 24th, 2007 at 2:48 am
Obviously the total remains the same, thus the “bad doctors” will get less, and the “good doctors” will get more…….and of course the docs will pay in time and money for the information systems they will need to feed “the beast”.
September 24th, 2007 at 5:41 am
ahh the old adage knowledge is power is so very often true. gotta love the insurance companies. but to be fair i like them better then the thought of the govt being in charge of health care, that possiblity scares the bejeebies outta me
September 24th, 2007 at 7:42 am
Dr. Rob,
A frustrating situation, and the balance of power definitely not in our favor. How do you propose action? It seems that we need to pool ourselves as ‘customers’ of the insurance companies so that we can influence the impending inanity. Doctors on the whole seem too apolitical.
Dr. Smak
September 24th, 2007 at 12:19 pm
If only doctors knew that the P4P measures aren’t determined by careful analysis of “quality,” medical research and patient outcomes. Number crunchers and marketing people are making a surprising number of the decisions. Sit in a meeting at a national insurance company when they’re creating their comp measures and rate charts — it’s sales and marketing staff with no medical background and the conversations are unbelievable. “How about 3 days…yea, that sounds good….” Doctors are actually working for the insurance companies, as they see it, and are merely helping them steer most members (generally more healthy than not to even get insurance coverage) to interventions, labwork, and prescriptions that MAKE the insurer money.
September 24th, 2007 at 1:25 pm
Very frustrating.
September 25th, 2007 at 12:51 am
Agree with a lot of what you say Doc. But some of your problems exist in your own profession.
I use to underwrite medical malpractice for the oldest property/casualty company in the nation, (now a part of CIGNA). Can’t tell you how many incompetent physicians I saw. People who actually belived that they were competent in their specialties. Then there were ones like Dr.DeBakey in Houston, who was a pioneer, but was sued many, many times even in the face of signed releases. We never paid a claim, but we spent a fortune defending him.
And you surely don’t want government handling medical insurance. Just look at the fraud in Medicade in states like New York and Florida. In the billions.
And that’s another reason to look at members of your profession. Far too much fraud.
For me, I did a little research before moving to where we now reside, and I picked the physician I wanted to treat me. And I think I picked the right person.
September 25th, 2007 at 1:45 am
I don’t disagree, Wolley. Would I let physicians police themselves? Of course not. As a physician, I see lots of bad doctors out there. I honestly think the benefit of P4P will be that bad physicians are rooted out or exposed. I just think the system is much more efficient if the information is managed at the physician level rather than through manipulation by third-party payers. I am not a big fan of the government running things either, but that is not the point. It is not who pays for things, it is who manages the resources.
September 25th, 2007 at 4:36 am
Got a question for you regarding malpractice insurance.
Would you be willing to trade a small portion of your fees to fund a no-fault type of insurance coverage, which would be purchased by each patient you see as they visit your office?
Patients would be automatically afforded the coverage but would waive their right to sue.
September 26th, 2007 at 7:28 am
I’m looking for a copy of the Family Practice Management of 6-14-2007 to read the article on insurance company payments to physicians. This was a survey of physician’s experiences with different companies, from one synopsis, Medicare rated better than most of the major insurance carriers. Could insurance companies be headed down the road of the unions back in the 50’s and 60’s? They buried Hoffa somewhere, how many will the insurance companies bury?
September 27th, 2007 at 5:09 am
“Medicare rated better than most of the major insurance carriers”? No kidding!
With the level of fraud in medicare, why wouldn’t many physicians love it?
September 27th, 2007 at 5:16 am
Wolley:
Sorry I didn’t answer your question: No I would not accept less for less malpractice. As a primary care physician, I don’t have bad problems with malpractice. It’s just not a primary care issue in general. Plus, I don’t think it would ever be possible patients to give up the right to sue. I am not even sure if I think I would want that. True malpractice still happens. What recourse do patients have in that situation.
Medicare is no fun for us. It just pays pitifully. The only reason I keep it is because I love the geriatric patients.
October 1st, 2007 at 9:39 pm
Great post-and kudos to you for your response “I love the geriatric patient