Ch. 3: DOES THE SYSTEM ALLOW THE BEST CHOICE?

Managed Care Insurance companies and governmental agencies will have miniscule interest in details of perioperative care. The economic system does not integrate the value of the patient’s postoperative well-being and comfortable, rapid recovery into the formula for defining payment. Value to an insurance company or hospital is derived from their bottom line profit and appeal to shareholders. Different techniques of hernia repair have different overall value to each patient but are valued the same by these insuring agencies. The variable costs in time, equipment, training and experience for both the surgeon and the operating facility are not compensated. If a surgeon is required to perform a large number of procedures each day in order to earn his/her living, each operation will be done with time constraint. The patient should know that these variables alter availability of offered techniques and he should know enough to explore the technical options that he will learn from this book.

 

The patient must be informed in order to interpret advice.

Surgeons may limit the options of types of repair offered for a number of egocentric yet realistic reasons. The economics of surgical practice require retention of patients. If one surgeon refers to another because of limits in his time, armamentarium or technical ability, the referring Primary Care Physician (PCP) may not refer similar future cases. With low reimbursements by Medicaid, Medicare and HMOs, some repairs might be avoided in complicated cases. High volume surgery requires speedy technique and sometimes possibly skipping some small steps that have only a small chance of adversely effecting outcome. Some surgeons may consciously actually accept the possibility of a recurrence rate unacceptable to others but still within the limits defined in the surgical literature. The facility in which the surgeon works may discourage laparoscopic technique because of increased costs of materials. Plugging defects with mesh is quicker than defining the defects and reconstructing the anatomy.

 

Patients have come to think that hernia surgery is minor surgery that always can be accomplished in less than an hour. Larger and complicated hernias take more time to repair. Unrealistic expectations lead to dissatisfaction. Partially informed patients quote “in-vogue” techniques derived from newspapers or the Internet as the one-and-only technique of choice. The logic of repair based on anatomy, physics, wound healing, planning and surgical technique and low recurrence rate may not be clarified. An idealist might assert that the Surgeon, who is a Physician and a professional should do the best procedure regardless of compensation. Government and insurance companies determine remuneration unilaterally at the lowest possible level and there is no significant adjustment for complexity or special skills. Net financial pressures force surgeons, who are after-all in a business, to compromise. An informed patient can help nudge his surgeons in a desired direction. A concerned surgeon’s instinct to perform a successful and artful operation will uniformly respond to the best considered choice If the best choice is not available, the patient must know to move on.  Does your insurance or HMO company share your interests?

 

Does your insurance company influence your access to surgeons?

Insurance companies sell different types of health care policies for different prices. These companies are businesses that sell products with the aim to make profits. In fact they consider the cost of providing health care to be a business expense not a service cost. Their stockholders examine the financial statement to see that this expense is as low as possible. The residual determines higher profit reflected in higher stock value. These companies are responsible to their stockholders, not to patients. As a business their mission is to deliver a profit and maintain growth in the value of the stock. Quality of care impacts only when policyholder dissatisfaction leads to a change in carrier. This change takes years to occur as the choice of carrier is that of the patient’s employer not the patients. We all know from newspaper articles that these insurance companies are not accountable for medical results. They have almost no liability and accept no responsibility for altering decisions that effect health care. Even Congress has been unable to change this.

 

Most companies sell the same products and use similar tactics to make profits. Practicing physicians have no influence except in the choice not to participate. These companies obviously changed the character of health care, provider commitment and satisfaction and have altered the physician-patient decision-making process.

 

Let’s consider just a few clandestine ways that these companies change your options and decisions. If you knowingly contracted to purchase an HMO plan, you knew that you have given up choices to be treated outside a specific network of physicians. This includes specialists if you need surgery or really get sick. Your premium (cost) is lower, your options are limited with your agreement, and your company pays providers much less (about 20% of normal fees). If you are in a capitated plan or your PCP is in a multispecialty group, you may think that you have access to any specialist in a book listing specialists in your plan, but economic incentives will almost force your PCP to refer you to the specialists in his practice group or risk sharing group. If you go elsewhere, your PCP’s and /or his Practice group will loose money. You will be referred only to his group’s one or two specialists. Your choices are almost nonexistent.

 

Techniques get even more devious. You or your employer have researched and evaluated different insurance products, with various deductibles and coinsurance requirements, and opt to pay a higher premium for a better product that allows for choice of specialist care. Your PCP cares for you either in or out of a preferred provider (PPO) network listed by your company. He may also care for HMO patients, or may be in a multispecialty practice group, an HMO pod (an informal association of PCP’s who share risk with other PCPs gathered by the HMO) or be involved in a Risk sharing arrangement involving HMO patients with the HMO or his hospital's  PHO (Physician-Hospital Organization). If you have a surgical problem, you assume that your PCP is your advocate and will give you options of referral to the best possible specialists. After all, you did pay for a policy that allows you to go out of network if you share some of the costs. Your PCP still has a financial incentive for referring you to Surgeons in his practice or another risk-sharing group. If he is in any risk sharing arrangement with an HMO, the insurance company that sells the HMO policy may link risk to any policy sold by that company, including your special plan. If the PCP is responsible for losses within his risk pool, the patient who exercises the choice that he purchased at a higher premium with cause a financial loss to his PCP if this patient goes to a hospital or specialist outside the risk sharing group and the insurance company pays a fee to the out of network hospital higher than that agreed by the risk sharing group. Your PCP’s group, pod or PHO will be financially penalized if you exercise your choice and your PCP will share the loss. You erroneously think that because you purchased a more expensive policy that you will have more choices. That company will still guide you to the Hospital and Specialist with whom your PCP shares HMO risk because their Risk Sharing agreement captured all patients with any policy issued.

 

 

These complex scenarios get more convoluted. The risk group may involve a group of PCPs, a limited number of specialists and the Hospital at which they usually treat patients. The majority of PCPs are not employed by the hospital. The HMO as part of the Risk agreement distributes capitated fees to the PCPs and Hospital. The PCP has 1000 HMO-X patients in his practice. He receives  $15 per patient per month (PPPM) for all services whether sick, well or absent. The Hospital receives $110 PPPM for all hospital care. The Insurance Company skims off the remainder up front. The remaining portion of the cost of care, premium less profit less Total PPPM is held to cover any additional laboratory or specialty care. Even the basic HMO patients have their options undermined. They thought that they would have access to all hospitals, physicians and specialists in the HMO Network. Now they are limited to a single risk-sharing group.  The biggest loss to the risk group will result from your decision to go to another hospital. When your insurance company pays the other hospital and other specialists, the risk sharing group must make up and payback the insurance company for the services that they did not provide or the extra expense for going out of network for care.

 

How can the Risk Pool Administrator coax your PCP to send you to specific Hospitals or Specialists?

Cash incentives work well. Cash incentives for referring patients are illegal only under Medicare Law. Otherwise, it might be taboo, but there are no legal restraints. The Hospital in the Risk Pool may use its own PPPM to augment the PCP’s PPPM and link this to referral to that hospital. This will obviously require audits by the administrators of the risk pool to assure that patients are indeed sent to the interested hospital and specialists. If the patients still go elsewhere, and exercises a contractual choice, the PCPs will be penalized by withdrawal of the Augmented PPPM.

 

Who are these specialists?

Do they include senior surgeons with extensive experience? Are all specialists equivalent? Will these specialists render optimal care for a cut-rate payment? What is your real relationship with a PCP whose judgment is impacted by economic incentives? Other patients’ experiences, the Internet and reference books are valuable sources of information.

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    A. Douglas Heymann,
    MD, FACS.
    Over 50 years of experience.

    Dr. Heymann

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