Patient fragmentation and healthcare reform
Art by donna K mcgee
How many health plans have you belonged to?
If you are old enough to read this, you are the exception if you can count them.
Because you weren’t paying attention before adulthood, we will ignore the number of times you changed health plans as a child.
Maybe you are one of those very few employees who has stayed in the same job your entire working career. Even then, your employer has most likely changed health plans several times during your career.
And then you will retire.
How many health plans may you encounter during your life time?
The plan(s) you were in as a dependent on your parent’s plan.
Your employers’ plans.
In the military? Add Department of Defense plans and the Veteran’s Administration.
Down on your luck? Add the state Medicaid program for yourself or your children.
Ever injured on the job? Add workers’ compensation insurance.
When you turn 65 or become disabled! Add Medicare and a supplemental Medigap policy.
All those different plans would not matter if health plans only paid bills.
If only it were so simple
Each plan has its own network of physicians and hospitals that agree to accept that plan’s level of reimbursement.
Each plan has its own medical guidelines.
Each plan has its own drug formulary.
Each plan has its own benefit design features that determine what is covered and not covered.
Each plan has its own bureaucratic processes.
Changing plans changes your care relationship
When you change jobs, or when your employer changes health plans the relationship between you and your doctor changes. Your doctor may not be in the new plan network. You may need to change doctors or pay more out of pocket to stay with your current doctor.
Treatment that was authorized by the former plan may require reauthorization or may not be authorized at all. Drugs that were covered under the former plan may not be covered under the new plan.
Your doctor’s office now has a different process to get paid. It may be familiar or an entirely new one.
What a doctor or other medical provider has to deal with
Multiple levels of reimbursement
Different sets of medical guidelines
Different drug formularies
Different sets of covered services
Is it any wonder that that providers are frustrated and may chose to ignore all of them? The patient is put in the middle. What the provider and the insurance plan can’t agree on falls onto the lap of the patient.
This isn’t just about different insurance companies and different health plans. Each employer plan over a certain size has wide latitude in the design of its own plan. The potential variations are limitless.
Some consequences
Provider information systems must focus their first efforts on getting paid. An understandable impulse. A much lower priority is patient medical information.
I have experienced this personally. Over the last ten years, I have received treatment for my bad knees from an orthopedic practice at a major teaching facility here in Washington DC. After about two years between visits, any trace of my medical history disappears. But they never lose track of my billing information.
Drug formularies illustrate how the patient is too often caught between health plans and physicians. Each pharmacy benefit manager has its own list of “preferred” drugs. In one, Lipitor might be a preferred drug. In another it is a non-preferred drug, compelling the patient to either pay more at the counter or challenge his doctor’s medical judgment.
Supporters of the status quo argue consumer choice. But is it fair to expect a patient to challenge the very judgment of the professional whose judgment he is relying on? Not to say that consumers shouldn’t challenge their doctors. But to expect consumers to leverage the cost management strategies of a health plan is unfair.
When doctors and hospitals and other medical providers have to untangle the maze of conflicting and confusing requirements of the myriad health plans just to get paid, is it any wonder that providers are frustrated? The patient is put in the middle. What the provider and the insurance plan can’t agree on falls onto the lap of the patient.
This isn’t just about different insurance companies and different health plans. Each employer plan over a certain size has wide latitude in the design of its own plan. The potential variations are limitless.
Consumer choice or a costly mistake?
Drug formularies illustrate how the patient is too often caught between health plans and physicians. Each pharmacy benefit manager has its own list of “preferred” drugs. In one, Lipitor might be a preferred drug. In another it is a non-preferred drug, compelling the patient to either pay more at the counter or challenge his doctor’s medical judgment.
Supporters of the status quo, argue consumer choice. But is it fair to expect a patient to challenge the very judgment of the professional whose judgment he is relying on? That is not to say that consumers shouldn’t challenge their doctors. But to expect consumers to leverage the cost management strategies of a health plan is unfair.
Does it make sense that patients should wander during their lifetimes through different health plans with a maze of differing rules about reimbursement and medical treatment? How do they begin to understand how best to use the medical system?
Doctors and hospitals and other medical providers have to untangle this maze of conflicting and confusing patient delivery systems just to get paid. Is it any wonder that patient care takes a back seat?
Patient care? A back seat? Am I stepping on toes? I will attempt to tackle this next time.
