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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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