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Life Health > Long-Term Care Planning

On the Third Hand: Paying the Doctor

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Everyone wants to put the consumer in charge of lowering health care spending.

That raises a question: If the current fee-for-service (FFS) physician reimbursement system is so dysfunctional that the Centers for Medicare & Medicaid Services (CMS) has a hard time making the system work for Medicare, how do we create a reimbursement system that gives consumers a fighting chance?

Today, consumers can barely find out after they’ve had an office visit what kind of care the office thinks it has provided, let alone what the care will cost in total, or what the patient will pay for care out-of-pocket.

Going to a hospital and trying to figure out what the charge might be for a relatively simple bundle of acute care — say, for example, fixing a child’s broken arm — is like trying to get a rain cloud to explain the mechanics of how water rises up into the sky and then comes back down. The cloud just does its thing without talking about it, and a hospital at least pretends to follow a similar approach.

The Senate Finance Committee organized a hearing last week on Medicare physician payment policy, to get ideas from private insurers on how CMS could fix the traditional Medicare fee-for-service (FFS) payment system.

Peter Edwards of Humana Inc., Louisville, Ky. (NYSE:HUM), talked, for example, about trying a system similar to an accountable care organization (ACO).

The ACO-like program focused on integrating care delivery, measuring performance, and paying doctors for helping to improve outcomes and control costs.

The program lowered the number of inpatient hospital days per 1,000 patients by 29%, and it lowered the number of emergency room visits per 1,000 patients by 46%, Edwards said. The program also increased the percentage of hospitalized patients who saw a physician within 7 days of discharge by about 15% and the percentage of people with diabetes who’d had the recommended A1c test by 6.1%.

Similarly, Lonny Reisman of Aetna Inc., Hartford (NYSE:AET), said his company found an incentive program helped decrease the pilot-program patient acute hospital admission rate by 45% when compared with the rate for control-group patients.

Then, as I was reading this, a couple of weeks after I’d surrendered and dropped out of my own employer’s generous, well-designed HSA program, it hit me: Most people with high-deductible health insurance and health savings accounts (HSAs) can’t start ACOs.

Aside from the fact HSA holders don’t have consultants, and usually don’t know what an ACO is, it’s hard for them (until recently: for me) to actually get the doctor’s billing person on the line, let alone hold a conversation with that individual. 

Pre-deductible HSA holders who are trying to dicker with doctors and hospitals are like open-pocketed lambs wandering timidly through a pasture full of FFS wolves.

Hiring a lawyer to manage $100 to $5,000 in medical bills per year makes no sense for the patient or the lawyer.

Hiring a patient advocacy service does not seem to make all that much more sense. Once, when I  actually tried to hire one, I was told I’d have to pay $500 just to get started. The bill I was mad about (for a routine, pregnancy-related diagnostic test) was for only about $500.

One way for an HSA holder to deal with the pre-deductible gap would be emulate the old health maintenance organizations (HMO) and pay one flat, “capitated,” per-patient fee for a year’s worth of routine care.

Some doctors with concierge practices offer a deal along those lines.

The problem is that, the last time insurers made heavy, well-publicized use of capitation, some providers mismanaged risk and went out of business. Patients accused others of skimping on necessary care.

My guess is that many doctors who succeed at setting up capitated concierge practices will end up skimping on care or rationing care by letting office waiting rooms fill up. The patients willing to wait forever will get care. The others won’t.

My modest proposal is this: Instead of HSA holders paying a concierge practice directly to provide routine care, they could band together to re-create a miniature version of the bone-crushing negotiators at Big Insurance Company Corp.

The HSA holders would hire health insurance brokers, benefit plan administrators, consumer advocates or others to buy the concierge-type care, verify whether the providers can make good on their promises, and take charge of dealing with the doctors and the billing people when the doctors don’t make good on their promises.

On the one hand, this system would be great. The HSA holders would pay a little more for care, but they could talk to sane, well-organized patient advocates and let the patient advocates deal with the horrors of communicating with the medical office billing people.

On the other hand, the reason this approach wouldn’t work is that the HSA Holders’ Fixer Service would soon turn into a limited-benefit HMO that would violate PPACA, HIPAA and dozens of other laws and regulations. And some of the negotiators would be a lot better than others.

And the third hand: If we as a country are going to make consumers have more skin in the game, then we have to figure out some new approach to medical services pricing and negotiations to keep the consumers from getting skinned. Assuming that consumers can go into the health care pasture with those medical wolves alone and survive is unrealistic.


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