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Nothing Assuring about Health Insurers

by Sally Ginsburg, MD

I recently read a New York Times article about the salaries of insurance executives that left me gobsmacked. Did you know the average annual base salary of insurance company CEOs in 2013, according to the article, was $544,000? (Wait, that’s just the base pay — annual total compensation is typically between 11 and 18 million dollars.) If the health care reimbursement process was a seamless one, then perhaps these numbers wouldn’t leave such a horrible taste in my mouth. But that’s not the case.

I doubt that I am alone in thinking U.S. health insurers have somehow negotiated themselves the deal of the century. They have managed to create a situation in which they collect huge sums of money in the form of premiums, not having to make payments until all the patient responsibility — co-pays, coinsurance and deductibles — max out. Once that maximum out-of-pocket limit is reached, then the payers are obligated to pony up their reimbursement payments.

The payment paradigm in health care is in the midst of a gradual, yet massive shift, from the classic fee-for-service model to a system that rewards value; at the same time, it has become increasingly difficult for patients or physician offices to contact insurance companies.

As health care providers, we are accessible seven days a week to see patients, that’s an expected part of being a doctor. Yet, many payers are not available to answer our questions beyond traditional business hours. One weekend I needed an MRI done for a child with symptoms indicative of a brain tumor. When my staff tried to get approval for the MRI they were met with an electronic phone system saying, “Please call back during regular hours.” Of course no one from the insurance company was in my office Saturday afternoon helping me explain to the child’s parents that they would need to wait the rest of weekend for more information. As a matter of fact, it seems that the insurance companies are much better at answering to shareholders than to the people who send them monthly premiums. Payers are setting the rules without necessarily playing in the game.

Meanwhile, insurance investment departments are turning millions in premium dollars into billions. They have created a behemoth financial industry for themselves, while the people they insure are pulling money and credit cards out of their own wallets to pay medical bills. One could argue that patients need to take responsibility for their own health and for their policy selection, but understanding what is covered and not covered in a policy takes more education than most people have and, frankly, more than I have.

As medical providers, we know how difficult it is to help ill people manage their lives. The current system relies solely on providers and their staff to deal with the patient fallout: rejected prescriptions, prior authorizations for medications, formulas, durable medical equipment and imaging studies. Essentially everything the insurance firewalls deem too costly or unnecessary. These same companies often tell us what we should be doing, what we have not done properly, and what we need to plan on doing.

I would estimate that about 20-30% of my patient calls to my office are related in some way to a patient’s lack of access to their insurer. Here’s an example that happened just a few weeks ago: I was sent a notice that a patient’s medication was no longer covered. I changed the prescription to a formulary medication… which was then rejected. The payer followed up with a prior authorization form. After our staff spent another ten minutes on the phone, responding to at least ten computer-generated queues, they were placed on hold with a message saying there would be a long wait due to “higher than expected volume”… In the meanwhile we are taking calls from the frustrated family wanting to know why their prescription is not at the pharmacy. Ugh!

I must confess that I haven’t always minded my manners on the phone with insurers when I’m fighting for what I think is right. I have written nasty things on prior authorizations, frustrated that a particular prescription may not be approved for coverage. I have even threatened to call the local newspaper if a child was not given the nebulizer she needed for an episode of asthma. It’s not pretty. My patience is wearing thin. I also don’t have much energy left for the silly letters I get from insurance companies, asking “How many calories?”, “How many cans of Pediasure?”, “How many diapers per month?”, “Maybe you should consider doing this.” I mean they have not even laid eyes on the patient!

Here’s an idea: What if the compensation model for payers changed in the same way it’s changing for providers—create accountability by directly tying pay to value. What if insurance premiums were only paid when the insurance payer provided good service? Even if we could create a series of indicators by which to measure quality service, a change would be unlikely. The health care insurance industry spends billions lobbying in Washington, DC. Where are the physicians’ organizations, the AAP, AMA, AAFP? What are we as providers doing in our own defense?

Despite all the frustration, my wish is for physicians to do just what athenahealth does – forge a working relationship with the insurance payers. Remember, the annual athenahealth PayerView report does more than reveal the insurers that are difficult to work with; it also highlights those that are easiest to do business with as well, that are making life easier for health care providers and their patients.

I hope that we can figure out a way for providers, payers and patients to work together to build a better system. Until then, I will continue to act in impolite ways as necessary, until the payers prove me wrong and deliver service that this nation’s caregivers — and more important, patients — truly deserve.

Dr. Sally Ginsburg is an athenahealth client and a pediatrician at Pioneer Valley Pediatrics in western Massachusetts.

Dr. Ginsburg is a pediatrician at Pioneer Valley Pediatrics.

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