I believe there to be a fundamental disconnect between typical health insurers’ provider reimbursement strategies and the long-term good of our health care delivery system and its financing.
Let me give you some examples which I know to be true.
• Insurers still pay primary care physicians far less than most specialists. That perhaps was a function of the system adopted by Medicare to “measure” the demands of specific physician activities and pay accordingly. Specialist activities were rated higher than primary care activities. The gap between primary care and specialist reimbursement grew and grew. And what happened? Predictably, the best and brightest are avoiding low-paying primary care. Consequences?
• Shortage and aging of primary care physicians who are needed to keep us from requiring the much-more-expensive specialist and hospital care.
• Oversupply of specialists resulting in overuse, because if you build it, they will come.
• Keeping the focus on sick care, which is what most specialists specialize in, rather than well care.
• Devaluing E&M (evaluative and maintenance) activity, which is the heart and soul of the practice of medicine, requiring observation, patient knowledge and judgment.
• Not paying for needed counseling and monitoring, which means too few do it and there is no quarterback for a patient’s care.
Many hospice organizations provide acute care for terminally ill patients in a setting that is far more patient and family friendly than a hospital-based ICU, and at much less cost. And yet, many insurers (including Medicare) negotiate with hospice organizations exactly as they do with specialists and other providers, trying to achieve reimbursement at the lowest possible fee level, apparently without thought to whether that makes overall sense. Consequences?
• Shortage of hospice acute care facilities.
• Longer hospice-eligible patient stays in hospital ICUs.
• Bloated end-of-life expenses that could be mitigated.
• Significantly worse patient experience.
• Commoditization of acute care undifferentiated as to its cost.
Virtually the entire insurer-industry response to behavioral health-office visits and counseling is contrary to common sense and the good of the system (financially and otherwise) and its patients. They underpay psychologists and clinical social workers, the front line of counseling. They overpay psychiatrists, who largely are prescribers of meds. Consequences?
• Mental health parity remains largely a myth in reimbursement, despite claims to the contrary.
• Limits on behavioral-health office visits do tremendous harm. Behavioral-health patients do not overuse office visits! And limits create emergency situations, particularly during end-of-year holidays, that glut emergency departments and do tremendous harm to patients.
• Still no co-location and integration of behavioral and physical health.
• The best and brightest become psychiatrists, who these days seldom counsel. They dispense medications and “monitor.” All at overinflated costs.
• Tremendous shortage of professional counselors and burnout of those who are in the field today, because at today’s reimbursement levels, they can’t pay their own bills.
Insurers are paying physicians for telemedicine patient consults at a significantly reduced percentage of what is paid for a regular office visit. Consequences?
• Physicians resisting telemedicine visits, which are clearly needed, particularly for the elderly and chronically ill for whom travel is a hardship.
• Missed regular office visits that should be occurring.
• Exacerbated inconvenience for patients.
• Lack of recognition of the added cost and hassle factor of the technology and other expenses and workflow changes needed for telemedicine and potential additional malpractice exposure.
• Fewer “maintenance” and counseling sessions, which are badly needed for the chronically ill.
• Greater emergency room and inpatient use overall.
Permit me to share a truth with you. OFFICE VISITS NEVER BREAK THE BANK! Never. It’s the lack of office visits that exacerbates already existing chronic situations that result in inpatient hospitalizations and specialist involvement over extended periods that break the bank.
The other item that breaks the bank is the leveraged whammy of untreated combined psychological and physical health maladies, which are the single biggest drivers of fee-for-service Medicaid expenditures today.
Many insurers are not using reimbursement as the strategic tool that it can be to improve the delivery system and reduce overall costs of its own insured population. Just the opposite. The folks in the “Provider Reimbursement Department,” by whatever name, who have done trench warfare with physicians and other providers for decades, push for the lowest reimbursement possible regardless of whether it makes sense.
What if insurers doubled the per-diem reimbursement of hospice inpatient acute care? The per-diem charge would then be perhaps 20 percent of hospital-based ICU care. And the additional dollars would help hospice organizations build more facilities and capabilities to start moving more hospice-eligible patients out of hospital-based ICUs to much kinder and gentler settings at one-fifth of the cost.
What if insurers dramatically increased the compensation of primary care physicians, helped with their technology needs, and had, say, a medical-school loan-forgiveness program? Blue Cross & Blue Shield of Rhode Island did exactly that some years ago. What might be the results? I hear that there still is difficulty recruiting primary care physicians to come to Rhode Island to practice, but it has made life easier for those who are here. We need more primary care physicians to keep us out of hospital inpatient settings.
James E. Purcell is a board member of HopeHealth, a hospice and palliative care provider in Rhode Island and Massachusetts. He also is the former CEO of Blue Cross & Blue Shield of Rhode Island.
