Blog | Tuesday, July 16, 2013

Your insurance is driving your doctor crazy

In this space we've discussed the shortage of primary care doctors in the US, a problem that is going to worsen as Obamacare increases the number of people with access to doctors. This means that primary care doctors like me are going to be even busier. But busy with what?

Historically, doctors have been paid by how much they do: how many procedures, patient visits and tests. This led to increasing costs as the market drove doctors and hospitals to order more tests and do more procedures. To stem this hemorrhage, both government-administered and private insurers are moving toward paying for quality of care. No one knows exactly what this means, including the insurance companies, but the essence is that costs are being shifted away from the insurer and onto the doctor and the patient.

One way to take away incentives for over-treatment is to allow for billing based on certain quality measures rather than quantity of care. What this means in practice is that I get paid less for treating the patient, but can make up for it (sort of) by billing separately for services that would normally be part of a full visit. This has led to awkward conversations with patients ("Why was I billed for alcoholism screening? I'm not an alcoholic!").

This has also given birth to a complicated system of incentives aimed at both patients and doctors. Your policy, for example, may require you to go online and fill out health information. While you're doing that, your doctor is also going online to fill out forms about your health. Your insurer may tell you that you will pay more if you don't lose weight or quit smoking, adding "moral hazard" to your health care.

This cost-shifting is very apparent to patients who are paying higher deductibles and larger percentages of medical bills. What they don't see is how their doctor is paying.

Nearly every insurance plan has a different set of incentives that allow doctors to collect more payment (or, in practice, avoid penalties). This means scouring charts, entering data (most of which is already available to the insurance company) and in general trying to figure out how these programs work. Say, for example, my practice sees 500 people from a plan that pays us when our patients meet certain health goals. In practice, this means going over each chart regularly (monthly would be best), looking for new data, and entering it into the company's database.

As one insurer told me when I asked how other doctors get this done, "They don't. They just give up the payments." Doctors often participate in several plans with different but equally Byzantine requirements and different data collection regimes.

This also means that your doctor is financially penalized when you don't follow their advice. If you don't get your colonoscopy, your doctor might lose some bucks. This could mean your doctor pesters you more, or it could mean that doctors will simply dump patients who aren't perfect little soldiers.

Remember, this rant isn't just a doctor kvetching. These programs will hit your wallet, and may cut off access to your doctor, either because they're too busy entering data, or they don't want to risk being penalized for your behavior.

No wonder we have a shortage of primary care doctors.

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog at Forbes. His blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.