The invitation looked harmless enough. One of Chicago’s largest health insurance companies was coordinating an evening meeting with physicians to discuss “the future in healthcare.” I knew this was coming. For the past few months, insurance companies had been conducting staff meetings at the larger medical groups to give physicians a reality check on their futures.
At this particular meeting, everyone was pleased that cocktails were being served to numb the inevitable blows. (When insurance companies organize smaller meetings of physicians, especially those that follow an audit of their medical records, there is no alcohol, just plenty of water bottles for everyone’s dry mouths.) At the very end of the presentation, when all the insurance company cards had been laid before us, I thought to myself I’d never heard anyone speak from a podium for an hour and at the end receive neither polite nor scattered applause.
The speaker at these evenings is always a physician employed by the insurance company. His/her title is medical director (I begin to think there must be dozens and dozens on their payroll) and he always begins by reassuring the audience that he was in clinical practice himself so he understands something of what physicians–especially primary care physicians–are facing. I view this physician more as a “Judas steer,” the animal that leads an innocent but doomed herd of cattle through the slaughterhouse corridors to the killing floor.
Dramatic changes ahead
In the most pleasant delivery possible, and with an occasional knowing chuckle, the medical director told us we should expect some pretty startling changes to the health care delivery system. Since all this affects you, the patient, let me share some key points, including some additional details garnered from conversations I’ve had with physicians who attended their own meetings.
- The health industry hopes that individual medical practices and small medical groups will ultimately disappear from the landscape by being financially absorbed into larger groups owned by hospital systems. It’s more economically sound for the insurance industry to deal with several large medical players than thousands of mom-and-pop operations. A health care consultant specializing in these mergers and acquisitions told me her firm was unbelievably busy, that small practices were being vacuumed up all over the country. In this construct, doctors who’ve owned their practices for decades sell to a mega-group and become employees.
- With the merging of her practice and doctor as employee, the nebulous “practice style” she’s developed over the years vanishes overnight into a standardized one, molded to the guidelines of insurance company medical directors who are, in turn, employees themselves. The doctor may be mortified by this, but is helpless as she’s likely cashed a sizable check and signed pages of binding contracts. The ultimate decision-makers in these vast systems are called health care executives. They’re usually non-MD MBAs, and we doctors refer to them as “suits.” Unless you cross them the wrong way (in which case reading up on witness protection techniques might be a good idea), health care executives are quite pleasant and very well dressed. Little wonder. They take home enormous salaries and stock option bonuses.
- The name of the game now becomes low-cost standardization of medical care. Physicians are expected to spend a limited amount of time with each patient, and are encouraged to see as many patients as possible during a workday. The insurance companies, sometimes with the token cooperation of a few physician-employees, create vast books of patient-care guidelines to which they believe their physicians must be “accountable” (remember this word, it will crop up again). These guidelines might mean documented Pap smear and mammogram frequency, weight management and exercise, colonoscopies for patients over 50, and getting that evil LDL (bad cholesterol) below 99 by any means possible. At first blush, creating such guidelines might seem reasonable, were it not for the annoying fact that patients are unique individuals and not one-size-fits-all Kmart socks.
- As a test run, the insurance industry, large hospital systems, and government jointly created a healthcare delivery system called Accountable Care Organizations (ACOs). They’ve tried it with certain Medicare patients, liked what they saw in terms of both savings and patient surveys, and now ACOs will be the health care of the future. To cobble together an ACO, hospital management (or a very large medical group such as Northwestern or Advocate), speaking for its salaried physicians, contractually agrees to provide all health care (primary care, specialty referrals, hospitalizations, etc) for a certain patient population–say Medicare recipients, employees of a particular company, or members of a union. For this, the hospital is paid a very large sum annually from which to fund the health care of their enrollees.
- If the prescribed guidelines are followed by physicians (i.e., physicians do what they’re told) and there is evidence, based on chart audits, that patients are getting “better,” then, in theory at least, health care costs will go down. If this scenario occurs, all the money paid at the onset of the project will not have been spent. The leftover cash is then divided among doctors as bonuses. On the other hand, if audits reveal a doctor’s patients are more costly than those of her colleagues, her salary for the year goes down. Let me stop here for a quick word about insurance company audits of your charts and privacy: there is none. When you enrolled in your health insurance program, one of the documents you signed allowed the insurance company to audit your chart without restrictions. Electronic medical records simply make the process, once done manually, technically easier. If you feel slightly nauseated by this, don’t worry. The insurer is looking at documentation, at cost numbers. They aren’t interested in you as a person.
- Let me reiterate this point. If the chart audit system discovers that a physician, for whatever reason, is an “outlier”–that she’s either not following the guidelines exactly or not getting the results anticipated for her patient population—she’ll be financially penalized. A quick example of what might occur: if your LDL is 115, you may be on the receiving end of a statin sales pitch from your doctor, not because bringing it down to 99 will improve your longevity, but because your refusal to do so will impact her financial bottom line.
- At first blush, you might say, “I think care should be standardized and physicians held accountable if they fail to comply with the guidelines of good medical practice.” Except, of course, the subtext of “standardized” always includes the unspoken “spend less money on the patient.” Thus, a doctor might be financially penalized for recommending nutritional counseling to lower cholesterol (“counseling is expensive”) instead of writing a generic statin drug (cheap). Or recommending psychotherapy (“therapy is very expensive”) instead of generic Prozac (cheaper than M&M’s). Or referring patients for massage, acupuncture, or even chiropractic (“expensive, expensive, expensive!”) instead of pushing an over-the-counter antiinflammatory (free to the insurance company, as it’s OTC).
- You might be saying “Isn’t this just like that HMO I was in once, but with bigger operators? When I was in an HMO, all I heard my doctor say was ‘sorry, you can’t have that.’” Yes, Virginia, this is just like an HMO, but with one major difference. If you hated your HMO, you could opt out and spend more money for good old-fashioned fee-for-service PPO (preferred provider organization) coverage. These were doctors who agreed to accept the insurer’s fee rate, but still had the freedom to order tests and drugs they chose themselves and weren’t penalized for doing what they thought best for you. The only problem? This PPO opt-out is headed for extinction.
- Let me close with a best-as-I-recall quote from an insurance company medical director. “We can no longer afford to pay for health care under the PPO model. Our plan is to phase out all fee-for-service care during the next few years. We’ll pay you doctors a finite amount of money to take care of a defined population. We tell doctors, ‘Don’t spend much money and you can keep the difference. Period. Don’t follow guidelines, and you’ll be leaving behind some serious money on the table and we’ll just take it back.’”
One physician piped up, “It’s one thing to have a healthy population of patients that never complains, follows all the rules, takes their generic medications, and never questions anything. But what about the non-compliant patients who won’t take the meds, don’t eat well, don’t have mammograms, continue to smoke? And what about super-health-conscious patients who want their vitamin levels measured and want referrals to acupuncturists?”
Another physician answered wearily for the medical director (who didn’t disagree): “You’ve got to fire patients like that. Get the non-compliant and the super-demanding out of your system. They’ll drag your numbers down. Hit your personal bottom line.”
Hey you, patient. Yes, I mean YOU. Pink slip time! Canned! Take your medical records and don’t let the frosted glass door hit you in the…on the way out.
David Edelberg, MD