• TMA's Hassle Factor Log Program

 Last year, Bent Tree Family Physicians, a Dallas-area family practice, decided to sever its ties to the managed care organization that covered 20 percent of the practice’s patients. The three physicians making up the practice believed they were losing control over medical decisions because the health plan was restricting many common procedures and medications, says Guy Culpepper, M.D., one of the founding members of the practice. "There were just so many heartaches with this one company consistently rejecting claims and refusing to pay," he says. While it was hard to see the patients go, he felt his only opportunity to help change the system was to halt participation—-to vote with his feet.

Frustrations like these are increasingly common in doctors’ offices across the country. To see the patients, you have to join the plans, which means you’ve got to agree to their terms—-reimbursement nightmares, credentialing hassles, restrictive formularies and all. Culpepper tells of a patient covered by a different managed care organization who had a mass of impacted earwax. Culpepper found it during a routine check-up, so he flushed it out. The procedure took approximately 15 minutes and required a quarter of a bottle of solution, he says. He billed separately for the procedure because of the extra time and resources used, but the insurance company denied payment by bundling the procedure with the check-up. In the letter accompanying the denial, the insurance company claimed that since the removal of the impacted cerumen was necessary to allow "proper visualization of the area," the procedure was "clinically integral to performing the ear examination." Of course, Culpepper had the opportunity to send written appeals on a couple of different levels, but how much staff time can be sacrificed for each claim that is down-coded or bundled in this way?

Credentialing alone is enough to drive a doctor up the wall, forcing many to hire additional staff. Each managed care organization has its own set of forms to be updated every year or two and in many cases, doctors must also submit updated licenses as well as renewal information on DEA and controlled substance certification. "In the old days we were credentialed by the hospital and that was it," says Keller physician and TAFP President-elect Justin Bartos, M.D. "We made sure they had copies of all those things," he says, adding that now between HMOs and PPOs, doctors might have as many as 30 entities requiring this paperwork. Many states have worked to create universal credentialing forms, but none have gained widespread national acceptance.

Referrals present even more hassles, since most managed care organizations require some sort of authorization, either by a form or a touch-tone telephone transmission. "I have 10 providers at two locations," Bartos says, "and I have a full-time person at each site that handles calls and interactions with the staff for referrals, plus we spend additional nursing time. So, I’m spending somewhere in excess of $75,000 per year in staff time to do referrals."

On top of this, most major managed care organizations require annual site inspections, which for a doctor participating in five or six plans means a staff member has to take the time to show an inspector smoke alarms, fire extinguishers, the thermometer in the refrigerator and whatever else is on the checklist several times per year. If there were one quality evaluative organization having credibility with all the plans, doctors could submit one form and have only one inspection each year.

The real monsters of managed care hassles are reimbursement issues and managed care negotiation. These top the list of most serious problems facing TAFP members, according to the most recent membership survey conducted by the academy. Doctors say insurance companies delay payment because of lost paperwork or electronically filed claims, or because they request additional information to authorize procedures. Many states including Texas have passed prompt pay legislation requiring "clean" claims to be paid within a certain number of days, but challenging the insurance companies on what can be considered "clean" leaves many loopholes in the system.

The Texas Legislature passed its prompt pay bill, House Bill 610, during last session, and according to TAFP Director of Legislative Affairs, Tom Banning, "we are still evaluating its effectiveness." The bill charges the Texas Department of Insurance to define a clean claim and it has only recently done so. Banning thinks it’s likely the language of the legislation will have to be adjusted once more data has been collected.

Restrictive formulary policies, like fail-first plans or step therapy, are supposed to help keep a lid on the rising costs of healthcare. But whose costs are being saved when insurance companies merge or rewrite their formularies at the time of contract renewal and requests to switch patients’ medications flood doctors’ offices? Each switch requires the physician to pull and examine a chart, call the patient in for an office visit, perform whatever tests need to be run and spend the time to explain the situation to the patient. Hardly any of this time and effort is reimbursed by the insurance company, so the doctor’s costs aren’t being cut. The patient probably has to take time from work to come in for a visit, so there’s no savings there. And there’s a chance the new drug won’t work as well as the old one, or worse, suppose the patient has an adverse reaction and has to be hospitalized.

Concerned about these issues, Dr. Bartos testified before the Texas House of Representatives Committee on Public Health last May, where he told the story of a 76-year-old woman who was a patient of one of his associates. She had come into the emergency room with abdominal pain, dizziness and vomiting and was suffering from a bleeding ulcer, according to Bartos. Her history showed she had been given a traditional anti-inflammatory medication two weeks earlier to treat arthritic back pain. Bartos says his associate would have rather prescribed one of the new Cox-2 Inhibitor medications, which have been shown to have a much lower incidence of intestinal bleeding, but the patient’s health plan wouldn’t allow it.

Based on the step therapy model, the plan’s formulary required she try two traditional anti-inflammatory drugs before she could try the new, more expensive medication, Bartos told the committee. "The patient in this case suffered a hemorrhage that may have been avoided and any money that was saved in the pharmacy budget was spent a hundred times over while caring for this one patient," Bartos says.

He suggests doing away with closed formularies in favor of a system of tiered co-pays, putting the incentive to save money on the patient. All drugs approved by the FDA would be on the formulary, but patients would be charged a co-pay based on the cost of the drug—-newer drugs with better delivery systems than their older counterparts or drugs with cheaper alternatives might carry a $45 co-pay. Traditional and generic drugs would still be $10 or $15. This way the patient can choose based upon the advise of a physician what side effects can be tolerated and when a newer, cleaner drug is necessary.

Make a Difference!
Sign Up to be a Key Contact

Compounding these frustrations is the sense that because of mergers, contract negotiations and the contemporary, high-turnover employment culture, family physicians are losing the ability to provide continuous care for generations of families and build the kinds of relationships they once could. A recent survey by the American Medical Association suggests physicians may be retiring earlier than in the past. The survey reports 38 percent of the physicians polled over 50 years of age intend to retire in the next one to three years. More than half of those reported their biggest frustration is managed care hassles and another 15 percent said the same of Medicare and Medicaid hassles.

When Austin family physician John Day, M.D., and his colleagues opened the doors at Central Family Practice in May of 1998, they made a decision more and more doctors are beginning to make. They opted not to participate in managed care plans, save one. They do accept Motorola’s insurance, but according to Becky Reyes, office manager at Central Family Practice, the company pays in about a week with no hassle at all. "We do get patients who are on PPOs or HMOs but are tired of messing around with them, so they come here for their sore throats and when their kids are sick," she says. Initial visits usually run about $60 and follow-ups are $55, and Reyes says they can almost always see someone the day they call if not the next.

According to Day, they decided to go strictly fee for service because they wanted to "do it right, and doing it right is really not allowed by most insurance plans." He adds, "we define doing it right as seeing our patients rather than calling in antibiotics on the phone for colds, spending enough time with our patients to understand what their problems are." While he admits starting the practice was slow and they don’t make as much as many physicians, Day says the level of job satisfaction is worth the sacrifice. "None of us goes home feeling frustrated by our day, that just doesn’t happen," he says, adding "and we’ve all been places where it did."

Before opening Central Family Practice, Day served as medical director for the People’s Community Clinic in Austin where he frequently stayed late hours making calls fighting for access to care in urgent situations. Now Day says he prides himself in giving attentive care, frequently spending as much as 30 to 45 minutes with a patient. "Bottom line—a lot of satisfaction and probably less reimbursement overall than most doctors would be able to pay their bills with," he says, pointing out the major problem with this practice model in today’s market. Also, by closing the door on insurance companies, Day and his associates have restricted their pool of patients, allowing only those who can afford to pay their health care out of their pockets and many doctors don’t see that as an option.

TAFP has heard the message from the membership that managed care issues top their list of concerns, says TAFP President, Lloyd Van Winkle, M.D. "The Texas Academy will best serve this by providing education to its membership, keeping them informed about … what their options are in dealing with these organizations," he says. The academy could take advantage of its educational capabilities to develop new workshops dealing with managed care guidelines, Van Winkle says. "You might be able to take your office staff to a TAFP workshop to learn steps they can take to improve their ability to deal with the requirements of these organizations."

At the suggestion of many academy leaders including Van Winkle and immediate past president Marcus Purvis, M.D., a new commission has been formed to directly address managed care issues. Though still in its formative stage, the tentatively entitled Commission on Health Care Services is intended to be a physician/patient advocate in the managed care arena, says Van Winkle, adding he would like to see the commission come back with recommendations for "some concrete, hands-on systems for dealing with specific problems with specific managed care organizations." It will meet for the first time at next year’s Interim Session with a full complement of 20 to 25 members. There will have to be some sort of data-gathering arm—-perhaps something resembling the TMA Hassle Factor Log project, which means TAFP members will need to speak out about specific problems they encounter.

Another venue in which the academy continues to push for change is the state Legislature. TAFP’s Key Contacts Program puts doctors together with state legislators to discuss health care issues and possible legislation. Members can find the Key Contacts volunteer form in this quarter’s issue of Texas Family Physician. Just fill that out and mail or fax it to the numbers provided on the form. Other opportunities exist for physicians to testify before health-related legislative committees—-just call Tom Banning at TAFP headquarters for more information.

"Being able to deal with change is the secret to long term survivability," Van Winkle says. "As a physician, you deal with change every day—-the systems you have to work in to provide care for your patients evolve. There are aspects of them you won’t like and those you will, … you have to evolve along with them." The academy will change to meet the needs of its constituents, he assures. And with the testimony, the action and the strength of its members, hopefully the academy can help alleviate some of the hassles standing in the way of good patient care.

Constant complaints of delinquent payments caused TMA to create a hassle factor log for the collection of specific reimbursement troubles with managed care organizations. Data are compiled and published quarterly and a comprehensive report comes out annually, laying out the hassles by type, by region, by plan and by specialty. With this information, TMA can target specific problem areas and begin negotiation with plans regarding ways to alleviate certain hassles.

Doctors can download the form from the TMA Web site, fill in the name of the carrier, the type of problem, be it down-coding, bundling, inappropriate denial or whatever, write a description of the problem and fax it back to TMA’s Department of Health Care Financing. There, a staff of three determines whether the problem lies in the doctor’s office or with the managed care plan.

"We try not to act as a collection agency for our members," says Theresa Devine, director of the department. "We hope the physician has done everything he can possibly do in his office to resolve [the problem]." Once it’s determined that the claim is clean and should be paid, a letter is sent to the payer to initiate a dialogue and a copy is sent to the Texas Department of Insurance. "We find that many times, a letter from TMA is all it takes to instigate payment," Devine says.

In 1999, the department received 3,322 hassle forms, each possibly containing multiple complaints. "That’s a 50 percent increase over what we did in 1998," Devine says, "and in the first two quarters of this year, we’ve seen a 40 percent increase over the first two quarters of last year." Last year, the department can document the recovery of around $185,000 for physicians because of this program.