Are you letting managed care organizations abuse you and your patients? In early network participation agreements, we were asked to discount our fees for the privilege of becoming a "preferred provider." These were simple financial decisions. How much will you discount your fees for the opportunity to see more patients? Losing some money was frustrating, but the decision did not require that we compromise our principles on patient care.
However, some managed care organizations (MCOs) are now injecting themselves directly in patient care decisions by approving or disallowing certain diagnostic and therapeutic procedures. In some cases, the reimbursement for certain procedures is so low that the procedure is paid below our cost. Visits are limited by frequency and duration, and per contract, the MCOs will not allow you to bill the patients for non-covered expenses. If you decide the patient really needs a procedure or a visit, you must provide it for the patient free of charge.
Injection into the doctor-patient relationship by the carrier in this manner is a violation that cannot be tolerated. They call it "oversight" for improved care, but it really is just cutting the bill. In attempting to work with these managed care organizations in the past, I have never received a call recommending that I take more X-rays, provide more care or add rehab (evidence informed care) to a patient's regimen.
MCOs are not attempting to improve patient care. They are only concerned with lowering the cost of the care and attacking the expense by lowering the fees, lowering the access and limiting the number of approved procedures. Plus, we need to remember that the managed care companies earn a financial bonus for not paying claims. They are paid a set dollar figure per member, per month. With these dollars, they pay your bill and get to keep the difference.
In the timely words of Dr. Bob Smith, if we don't leave MCOs that act this way, we deserve to have all insurance carriers treat us the same. If we allow this intrusion into our patient care decisions, then all carriers should impose similar limits. Actually, they should do this in fulfillment of their fiduciary responsibility to their shareholders.
These abusive MCOs only exist because doctors are willing to sign up as participating providers. They would evaporate overnight if doctors would refuse to commit to be providers in the network. This scenario played out in Vermont a few years ago when an abusive MCO attempted to get a foothold in that state. However, it was not able to get enough providers to sign up and had to move on.
When proper and appropriate patient care cannot be provided due to limits imposed by an MCO, we must make a decision not to support such abuse of our patients. We have an obligation to leave the network. Unfortunately, we cannot discuss leaving a network with a peer. To confer about this would be a violation of federal law. So, this is a moral decision that must be made independently and for the good of your patients.
When contemplating leaving a network as a participating provider, we often feel a strong sense of frustration. The decision becomes personal when we think of specific patients from whom we are walking away. We may feel as though we are abandoning our patients by leaving the network. Some patients will even express their frustrations with our decision as we explain why we were forced to leave.
Our desire to serve patients is one reason we became physicians. MCOs take advantage of our passion for serving our patients by forcing us into these difficult decisions. They are using our concern for patients against us and leveraging more profits for themselves on the backs of our goodwill. However, in these cases, to provide the best and the proper care for our patients, we must walk away from abusive MCOs.
Staying in networks that will not allow us to properly serve our patients has an ethical dimension. We are supporting companies that abuse our patients. We are working for a fee and compromising our principles on patient care.
Many have heard the old Winston Churchill story about a man who asks a woman if she would sleep with him for a million dollars. "Sure," she says. He then asks if she'd do it for $20. "What do you think I am?" she retorted. To which the man responded: "We've already determined what you are. Now we are merely negotiating price." If we stay in a network for the few dollars we can generate, knowing full well that our patients cannot get the care they need and deserve, we truly have prostituted ourselves. We no longer serve the needs of our patients; we serve the desires of the MCO.
I implore all doctors to take a hard look at the networks they participate in; with each, decide if you have the ability to properly serve your patients in light of the limits imposed by the MCO. If not, I recommend you leave. In such a case, leaving is the moral imperative, and you cannot put a price on that.
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