The New Health Insurance

Whatever happened to the good old days? When a patient used to enter the doctor's office with a complaint, the doctor did everything in his power to treat the patient, regardless of the cost, and then billed the insurance company. Patients did not leave the MD's office without a complete set of tests, a prescription for a drug to combat the problem, and perhaps a prescription for a drug to combat the side-effects of the first drug. This, of course, did not preclude the potential for some unnecessary surgery.

Many medical doctors (and a few DCs) became obscenely wealthy during this period, milking the system for all they could. They bought the expensive cars, the big homes in the best neighborhoods, and donned the accouterments that bespoke the successful doctor. Medical schools were flooded with applications of young people chasing the medical pot of gold.

But suddenly, without much warning, managed care rudely entered the picture.

"Cost shifting" became the preferred method of moving health care costs and risks from the insurance company to providers, without reducing policyholder fees. Sure, health care premiums have remained relatively stable over the past few years, but this is only because the insurance companies were too embarrassed by their record profits.

Providers were forced to join "panels" in an effort to provide the same care at a lower price. This "special" new arrangement came complete with a mountain of paper work to justify the new reduced fee.

Capitation was the bone thrown out to provider groups in an effort to make the lower fees more palatable. "Just think, you get paid every month, even when the patient doesn't come in!"

Fortunately, nothing stays the same.

For the past two years, managed care companies are showing disappointing earnings. The record profits lured plenty of competition. Now we have multiple managed care companies with the same providers chasing contracts with employers. The employers aren't willing to pay huge increases, and the providers have been ground down about as far as they will go.

So, what's next?

The next episode of the health care soap opera introduces us to a new kind of plan: case rate reimbursement. This is where a group of providers (specialty teams) is paid a single set price to address a specific ailment. They get paid a set amount, regardless of what it really costs to treat the patient for that particular complaint. If they spend less time and money on the patient, they make a profit. If not...

Notice how the roles are reversing. Instead of some medical director at some heartless managed care company denying care they claim is "investigational," now a conservative MD is telling the patient the care isn't needed, or that it won't help them. The MD's decision is reviewed and confirmed in a second opinion by a specialist. The specialist is of course part of the same team that is being paid the flat fee to treat the ailment.

In the past, the provider acted as the patient's advocate, demanding that necessary care be reimbursed by the insurance carrier. Now the insurance company may become the advocate demanding care for their policyholders!

Who would have thought of that scenario happening? The most ironic aspect of this latest plan is the PR spin:

"We designed this new model in response to our physicians' clear desire for more clinical autonomy and less intrusion by the health plan."¹

A looser translation of this might be:

"We designed this new model so that if our physicians want to spend money on costly procedures and expensive drugs, they can. But they can't spend our profits doing it."

Perhaps I am being too harsh. Perhaps the insurance carriers have the best interest of the policyholders at heart.

But you should always recognize that insurance companies have a bottom line to protect; that will always be their first consideration.

How would chiropractic fit into this new model? That's hard to say. As MDs place themselves directly under case management costs constraints, they may finally recognize how attractive the cost efficiency of chiropractic can be. Our value remains, despite the insurance medium that delivers it.

But as this or any other form of managed care evolves, you should examine it VERY carefully. Consider the role they've written for you; consider what rights your patients will have; and consider what responsibilities the insurance carriers will incur (or shift).
Remember, you have a choice. Just because the insurance carriers offer it, doesn't necessarily mean you want to be a part of it.

Reference

1. Stephen F. Wiggins, chairman of Oxford Health Plans, one of the first to offer an insurance product utilizing specialty teams, as quoted by PRNewswire, AOL News October 10, 1997.

Donald M. Petersen Jr. BS, HCD(hc), FICC(h)
Editor/Publisher Dynamic Chiropractic
Don@DCMedia.com