The quest for common ground

how TAFP is carrying your voice to the managed care companies

By Theron Dale Ragle, M.D.

When I set up practice about 15 years ago, I had just finished a four-year stint with the Air Force. I had left what I thought was an onerous bureaucracy to practice medicine. I thought I was entering the paradise of private practice that would surely enable me to spend more time practicing medicine and less time worrying about paper work. I would no longer have to deal with what appeared to me to be arcane rules and regulations.

After setting up my practice, however, I quickly realized that I was quite naïve. I found out that rather than needing to understand one set of forms and paperwork, I now needed to understand about 20. I now needed to understand the rules of engagement for each individual insurance company. I learned that my experience in the Air Force hadn’t even begun to teach me what it meant to be put on hold on the phone. Yes, I had finally learned the Golden Rule: He who has the gold makes the rule.

I am certain that many other, if not most, practicing family physicians can relate to my experience. What I heard from my colleagues was a lot of grumbling and complaining about the amount they were paid or the difficulty they experience trying to get paid. The topics in the doctors’ dining room were not about clinical medicine. They were lamenting about the current state of the business of medicine. What had happened?

You get different answers to this question. In my opinion, the root cause lies in the fact that advances in medical technology and pharmaceuticals and the public’s seemingly insatiable demand for them have outpaced our ability to pay for them. The already small piece of the finite health care pie held by the primary care physician is getting cut even smaller by CT, MRI and PET scans. The root cause of the problem is no fault of ours. However, some of us probably make the problem worse by over-utilizing these technologies. There are probably three reasons for this:

• As physicians we are trained to do the very best for our patients. If something is available to help us solidify our diagnosis or assist us in our treatment, it is our instinct to use it.
• The ongoing malpractice crisis and our fear of the plaintiff’s bar encourage the practice of defensive medicine.
• We seem to have the notion that both the physician and the patient are shielded from the high cost of health care. After all, the deep-pocketed insurance companies are footing most of the bill! We feel that we can do the very best for our patients and protect ourselves from litigation without regard to the cost of doing so.

I have heard a lot of talk amongst physicians about the first two. I have heard much less about the third. There is very little peer oversight for physicians in private practice with regard to use of health care technologies and necessity of services provided. Unfortunately, if we don’t police ourselves, someone else will.

Of course, the notion that we are shielded from the cost of the tests and medications we order is false and absurd. We must not forget that insurance companies are in the business of making a profit. That is their fiduciary duty to their stockholders. The money that pays for those tests comes from premium dollars that our patients pay. Furthermore, the insurance companies want enough premium dollars coming in to pay for health care and to make a profit. When the money going out of the insurance companies’ coffers exceeds what comes in, our reimbursement suffers and our decisions are questioned. The increasing hassles associated with questioning our decisions make it more difficult to spend the time to deliver quality care. This is intensely offensive and frustrating to us, but no amount of grumbling is going to change it. There’s simply not enough money to pay for burgeoning health care technologies and pay us what we think we deserve.

I am certainly not naïve to the fact that there is corporate greed on the part of some, if not all, insurance companies. Some of their CEO salaries seem obscene and there is certainly mismanagement in their own internal bureaucracies. However, we can do nothing more than whistle blow about this. What we can do is become part of the solution by developing a respect for the health care dollar and attempting to educate our patients to do the same. I sometimes think that the more the premiums go up, the more the patients demand. After all they are paying a lot of their hard earned money to the insurance companies. Unfortunately, this becomes like a snowball rolling down hill. The more premiums they pay, the more services they demand. The more services provided, the more the premiums go up and so on and so forth. Patients need to understand that they are paying for those tests in the ever-increasing premium dollar. Even in cases where the companies that our patients work for are paying most of the premiums, the ever-increasing costs to the employers will ultimately manifest itself either through limited coverage or lower salaries. Employers are squeezed between maintaining their bottom line and meeting the needs of their employees. Business groups are becoming increasingly angry at the health care system. Being a small business owner myself and seeing the increasing cost of health insurance premiums, I can understand some of their anger, although I strongly disagree with some of their positions and tactics.

About a year ago, I became involved with the TAFP’s Liaison Task Force with Managed Care Organizations. This task force was originally charged with meeting with the leaders of various managed care organizations to discuss “pay for performance” and other issues. Pay for performance is a new buzz phrase in the managed care community, which purportedly rewards physicians financially for “good performance.” Currently “good performance” is ill defined. One of the things that we wanted to do was to make sure that “good performance” means good quality of care. There were deep suspicions among much of our TAFP leadership that “good performance” was going to be measured mostly on economic performance and not quality of care.

The TAFP Liaison Task Force has thus far met with Blue Cross/Blue Shield and a contingent of us is meeting with United Healthcare. We are planning to meet with other companies. Monitoring certain quality indicators by analyzing claims data appears to be the method of choice for measuring quality of care, at least for now. This is what has been done in other parts of the country. One example might be using claims data to verify that diabetics are getting periodic hemoglobin A1c measurements or that post MI patients are being put on beta blockers. This may not sound like much but it is a start. Attempts are being made to use quality indicators that are non-controversial and are true national standards of care.

While no company has yet rolled out a true pay for performance program in any market in Texas, Blue Cross and United Healthcare are forming separate networks of physicians that they consider high performers. It appears that they are moving in the direction of true pay for performance programs. We are getting involved early in the process in an attempt to influence the direction they are headed.

The pay-for-performance train is leaving the station whether we like it or not. The only way to influence the speed or direction of the train is to be in the engine car. We must continue to meet with the leaders of the managed care organizations to attempt to influence the speed and direction that they are going. Only by recognizing the problems in our health care delivery system and attempting to become a part of the solution can we hope to ensure that any changes made to it are true reforms beneficial to our patients, to physicians and to payers. In short, if we don’t become part of the solution, there is a high likelihood that we will not like the end product of any changes made.

We are attempting to bring the message that the only acceptable pay-for-performance program would be one that pays for quality of care as well as cost effectiveness. We are also trying to hammer home the message that reducing managed-care-imposed hassles will improve quality of care.

At the same time, we must begin to police ourselves better, which will increase our moral authority to blow the whistle on the excesses and abuses of some managed care organizations. Only by cleaning our side of the street can we demand that someone else clean their side and get others to rally with us. The alternative is to be continually reactive rather than proactive and continuing our past pattern of playing the victim role rather than being agents of constructive change. It is my hope that our profession as a whole will follow us.