We would like our patients to be aware of some current issues concerning our ability to continue to participate with health insurance plans. We are facing dramatic cost increases with little or no reimbursement increases. Many of the insurers have created  administrative burdens for primary care doctors' offices by putting in place policies requiring pre-authorization for everything from testing to prescriptions, in addition to the already burdensome job of authorizing referrals. We are finding that we are often halted in our tracks during the course of the day by the need to stay on-hold for as long as 45 minutes at a time waiting for permission to obtain a service or treatment or medication for a patient. This blocks incoming calls from patients.

We are spending more and more time faxing and completing forms. We are regularly being asked to complete a lengthy document simply to allow a patient who has been taking a common drug to continue receiving it. If we refuse to do so on the grounds that this usurps inordinate amounts of our time and patient care availability, our patients suffer. We simply cannot afford to comply with these “cost-saving” tactics, however, as they in fact cost us dearly, and more important, they interfere with our best effort at taking care of our patients.

On average, we are able to recover from the insurers approximately 1/2 to 2/3 of our charges for a given service, after a delay. The payment process is costly and time-consuming. Fee schedules are fixed by the insurers. We are prohibited by the terms of our contracts from billing our patients for any balance due, as a dentist would. Major insurers typically refuse to negotiate terms with independent doctors, only large powerful groups. We have learned that most of our patients are surprised by these facts. If you believe that it is wrong in principle to prohibit “balance billing” as it is called, and would prefer to have this option than to have your doctor terminate your insurance plan, please let your employer, your insurer and your legislators know. The insurance commissioner of Massachusetts is also available to address complaints, although we have had difficulty in getting through in the past. Even as a doctor, I was not permitted to speak directly to the commissioner herself.

Increasingly, insurance companies are tying payment to so-called “incentive” programs. While presented as increased pay for certain practice behaviors they deem reflective of optimal care, they are, in my opinion, thinly veiled withholds of fairer pay, coercive and counterproductive, distracting doctors’ attention away from their patients, and emphasizing process over product. Typically, they reward things that facilitate management and control of doctors’ practice habits.

We have endeavored to facilitate billing insurers we do not contract with, as a courtesy to our patients. Unfortunately, we have learned that  insurers are using confidential billing and claims data (including required diagnosis codes) for reasons other than processing claims. I have formally objected to the insurance companies about this breech of privacy, only to be sent lengthy justifications for this practice. Many patient-related functions are now “out-sourced” to business entities, who then have access to confidential medical records. Boilerplate HIPAA agreements stand as carte blanche for the sharing of patient information with these parties. (Ironically, the same HIPAA tenets are regularly misinterpreted by support staff, resulting in delay of exchange of critical information among doctors.)

Many insurers are now authorizing nurse managers to contact patients directly, without the doctor’s knowledge or permission, to help “facilitate” cost-effective treatment of chronic (read, expensive) conditions such as asthma, diabetes and congestive heart failure. Claims data have also been the basis for the objectionable practice of “tiering” doctors, purporting to convey something about the quality of care rendered when, in fact, based on other, typically financial factors. More heinous is the policy of linking the copay to the tier-i.e.,lower tier, higher copay-thus funneling patients to the doctors who charge the insurance company the least, disregarding the factors that may influence those charges, such as an inordinate proportion of very sick patients. Pediatricians who see children with cerebral palsy and seizure disorders are a typical example. We believe patients are a better judge of who is a good doctor.

We intend to continue the fight for a fairer system, one which does not obstruct and discourage excellence in patient care, as the current system does. On the near horizon is a shift to paying doctors based on data mined from electronic medical records, or EMRs. As available EMRs are very expensive, and have failed, in our experience, to enhance patient care or protect patient confidentiality, we anticipate leaving third party insurance networks prior to that time. As we have found ourselves increasingly conflicted with respect to patient care versus service to insurers, we have resolved to make all decisions going forward guided first and foremost by the principle echoed in the words of the oath I took when I graduated from medical school at Brown: “The care of my patient will ever be my first concern.” 

For now, we encourage all of our patients to familiarize themselves with their individual policies. Seek out plans, like PPOs (preferred provider organizations) that will allow for out-of-network care with little or no penalty or referral authorizations, so that when the time comes for us to withdraw from the insurance networks, we will be able to continue to take care of you without interruption, assisting you with the submission of your own claims.We dearly hope that the partnerships we have built with you will persevere and thrive despite the challenges posed by the current health care milieu. You can be sure that we will continue to do our best for you.

Cathleen S. Hood, MD