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President's Page
July 2006
Transparency in Medical Care—
Ensuring that physician networks are adequate for health care
2006 DCMS PresidentOne aspect of the TMA Healthy Vision 2010 encompasses promoting transparency in health care. This policy involves several issues:
(1) Require physicians to disclose to patients any ownership interest in a facility or service. Having been involved in a multitude of physician-initiated ventures (a cooperative lab, a women’s imaging center, a perinatal testing center, and a surgicenter, to name a few), I believe these allowed us to provide a better, more economical service to patients than was available in the community. The patients were served; quality and safety were emphasized. Today’s ventures are much more complex and require a more formal patient notification.
(2) Require health plans to provide employers, patients, and other purchasers with accurate, up-to-date lists of contracted physicians, hospitals, and other facilities. This becomes much more important when the plans lack certain specialists in their contracts. The potential financial implications are significant.
Dr A admits Sally X to Hospital Y for a surgical procedure. Both Dr A and Hospital Y advertise that they are contracted with Plan Z. Sally arrives at the hospital and meets her anesthesiologist, Dr B, who is not a part of Plan Z but has an exclusive contract to provide anesthesia in hospital Y. The patient elects to continue with the procedure. The procedure goes well and the surgical specimen is sent to the pathologist, who also is not contracted with the plan but has an exclusive contract with the hospital. Initially, Sally does well postoperatively, but on Day 2 she has severe chest pain. The suspected diagnosis of pulmonary emboli is confirmed by the radiologist who, of course, is noncontracted and has an exclusive contract with the hospital. The hospital has an excellent intensive care unit, which contracted with Group C of intensivists which is not contracted with the patient’s plan. Sally X recovers and is sent home without any other complication.
Once the patient is recovering, the bills begin to arrive. They all are polite and explain that the services rendered are not covered by her plan and payment is due. They will bill her plan for “out-of-network payment.” If any payment is received, they will refund that amount to her. The bills mount from the anesthesia, pathology, radiology, and intensivists. Then the real shocker: a hospital bill which, of course, will be submitted to the plan. Sally X does not feel so well now.
Whose responsibility is the notification? It is incumbent that the admitting physician be knowledgeable about these potential problems. The TMA recommends that the Texas Department of Insurance develop and enforce stricter rules requiring health plans to provide their members with adequate physician networks. Transparency is the basic tenet of American business (TMA-Health Vision 2010). “The buyer must know what to be wary of.”
A tangential issue is balance billing. It is much clearer in emergency issues; however, the concept is the same with noncontractual services in nonemergency situations. In a recent California ruling, Medicare rates were deemed not appropriate. The courts did not rule on what method would be acceptable to determine a just fee.
Both the AMA and the American Hospital Association strongly support transparency. AMA states that physicians, pharmacies, durable medical equipment suppliers, and other healthcare providers should be required to make information readily available to consumers about fees prior to provision of service. Insurers also should be required to make information available in a standard format on the amount of payment provided. The AHA acknowledged that it is uncertain exactly what type of pricing information will be most helpful to consumers.
As we, as purchasers of health care, are faced with ever-escalating insurance costs and the decline in reimbursement for our services, we must ask, where is the transparency in the healthcare industry? The AMA’s latest study on the health plan market shows overwhelming domination by a few plans. One insurer has a 90% or greater share of combined HMO/PPO business in 11 metro areas. For PPO business alone, one insurer has a 90% share in 26 metro areas, and for HMO business alone, in 50 metro areas.
If the insurers are squeezing the public, physicians, and hospitals, how are their executives doing? William McGuire, MD, CEO, and chair of United Health Group, is sitting on $1.6 billion in unrealized stock option gains. He already has cashed in $488 million in options.
How much longer will we accept these injustices without demanding a change?
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