It’s really simple. We don’t pay primary care doctors fairly because we spend too much on health care and insurers (payers) have decided that the most effective way to control medical costs is to reduce fees paid to doctors and other providers. The other principal method is to deny payment or coverage.
Knowing this, it is relatively easy to understand why doctors, in the majority, report that they are dissatisfied with their careers.
In my view, the failure to pay doctors fairly results from a failure of imagination. Insurers simply cannot see the way to controlling medical costs except on the backs of doctors and policyholders. There is an alternative, however, that has worked in the past and can work again if applied uniformely across the country. It is a managed medical network.
To be effective, the medical network must pay providers fairly. This means that the fees paid must be fair and the medical community must be the arbiters of care… not the payers. With this system in place, we can ask the health care providers to cooperate in controlling utilization and over treatment. Bringing over treatment under control can reduce total medical costs by more than $600 billion per year. Paying doctors fairly is a small price to pay for the resultant savings. In addition, by eliminating waste in health care costs, we can help ensure that care will be appropriate. Thus, the patient benefits.
Posted in appropriate medical care, over utilization.
Tagged with appropriate care, care providers, doctors, managed medical networks, medical cost, over treatment, over utilization, pay doctors fairly.
By PBNesbitt
– July 19, 2010
Probably the most cited reason for over treatment and unnecessary medical care is the threat of medical malpractice. This is no idle threat. Physicians know that any bad outcome can potentially result in a lawsuit. There are plenty of lawyers who can codge together a case based on outcome alone. Insurers often settle rather than defend because it is less costly in the over all scheme of insurance. There is no benefit to the care provider, however, and a medical malpractice award can stain an otherwise stellar medical career.
By creating a National Managed Medical Network, we may be able to change the dynamics of medical malpractice. In our current system, the physician stands alone when a lawsuit is filed. In a Managed Medical System, the management of care and responsibility for outcome is shared. Any legal action, therefore, would be applied against the managed network as well as the provider. Someone now has the provider’s back. Together, they can defend their management of care. Of course, if there was truly malpractice, then the claim should be paid and the patient or patient’s family properly compensated. But if the claim is not just, then the network and physician must fight.
One might also consider removing medical malpractice claims from the current system of torts and placing it into an adjudicative system with a panel of administrative law judges.
This system, built around a Nationwide Managed Medical Network, could significantly change the face of health care by helping to free doctors from the threat of medical malpractice.
Posted in medical malpractice.
Tagged with managed medical networks, medical malpractice, medical networks, over treatment, over utilization.
By PBNesbitt
– July 17, 2010
Without implementing a national Medical Network strategy it is difficult to see how we can really save health care. Burdened by growing medical costs due to over treatment, health care consumes too much of our national treasure without providing any real benefit. As for us, the payers for health care insurance, premiums continue their inexorable rise.
Managed Medical Networks can change all that. By bringing all cooperative providers together into a single, well managed medical network, we can improve health care while taking out the trash (getting rid of waste and unnecessary care). The key is in having a single, non-competitive network. This will allow us to rationalize health care in a way that is impossible now. For example:
- The Network would provide health care services to all insurers and their policyholders; this would eliminate the possibility of health care providers playing insurers off against each other and setting their own fees – in other words, providers cannot game the system;
- The Network can collect data on best practices nationwide in one coherent database; this aspect is critical for rationalizing health care. If we don’t know what works, we can’t advise providers on best practices;
- The Network can pay providers based on negotiated contracts in which the objective is to pay fairly and promptly. Do we want doctors to prescribe based on clinical finding or do we want to fight with them? Pay them fairly and get them on our side;
- The Network can obtain voluntary agreements for all participating providers to provide services under the principles of “lean medical care”; that is, care providers only prescribe services indicated by the clinical findings; this is key to eliminating the waste and unnecessary care in the current health care system;
- The Network is managed by medical professionals, not payers; payers always are concerned with costs, the Network is only concerned with appropriate care for patients and factors necessary to provide that care;
- In a rational system, all participants must benefit equally; we must recognize their needs and respond clearly and unequivocally;
What the Managed Medical Network is not.
- The Network is not an insurer;
- The Network does not determine who gets health care and who does not; that is the role of the insurer, private or public;
- The Network does not ration care;
- The Network does not focus on cutting health care costs; rather, it trys to assure that all patients receive appropriate care as defined by “lean medical care” and best practices.
The use of a Managed Medical Network offers a type of health care reform that can truely work. It allows for a single payer system without government intervention. It lowers medical losses and insurance costs which can translate into lower insurance premiums. Most importantly, it is the only approach that can “Take Out The Trash” (lower costs) without rationing.
Posted in appropriate medical care, health care reform, lean medical care, single payer.
Tagged with appropriate care, care providers, doctors, health care costs, health care reform, health insurance, lean medical care, medical costs, medical networks, over treatment, single payer.
By PBNesbitt
– July 13, 2010
Our inept congress passed a health care reform law that included a 21% cut in Medicare doctor’s fees. All the talk now is about doctors leaving the medicare system. Others will simply seek new ways to game the system. One has to ask what were they thinking. Can continually cutting the fees paid to doctors support quality medical care?
It has been reported that there are hundreds of demonstration and pilot programs but they are stymied by a lack of provider participation due to lower payments. Maybe the answer is not found in lowering payments to providers. Perhaps we should pay them fairly. Now, there’s a novel idea. Why don’t our elected officials see this? Why do they fear fair and reasonable payments for something as important as medical care?
Perhaps we can find to answer in the nature of insurance itself. First and foremost, insurance is concerned with limiting losses and not paying claims. From its inception, insurance was viewed as a form of investment for wealthy individuals who were not investing to lose money. Today, health insurers operate in exactly the same manner. First deny the claim, second pay less whenever possible. When seen in this light, reducing the fees paid to providers makes perfect sense.
Now, in my own mind I make a distinction between professional fees and service fees such as those paid to hospitals, MRI centers, and so on. It is my view that professional fees should be based on usual and customary while service fees reduced to a minimum. After all, it’s the medical professionals we need working with us, not against us. I would be prepared to argue that all services should operate as medical non-profits. We should pay only the cost of the service, not a profit. But, of course, the real key is in limiting the use of these services. Too often tests, studies, and referrals only represent waste, not services necesssary to promote health. Pay professionals fairly and limit the use of services. Allow only appropriate care based on actual clinical findings and diagnostic impression not treatment for convenience or defensiveness.
Posted in health care reform.
Tagged with appropriate care, clinical findings, congress, diagnostic impression, health care reform, health insurance, Medicare, medicare cuts.
By PBNesbitt
– July 4, 2010
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