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The Rooster is in the Hen House

The Rooster is in the Hen House

I had several distractions over the holidays that prevented me from blogging. But, I am back. At the forefront of medicine today is healthcare insurance. I read the editorial page in the Commercial Appeal frequently and found the thoughts composed by Clay Phillips, Vice President of Network Strategy for BlueCross Blue Shield of Tennessee amusing. The headline of his commentary was, "We are starting at the center to transform health care spending."

His idea is a noble one: reimburse physicians based on quality of care, not quantity of care. According to his position, BC/BS promotes clinical quality performance by incentivizing physicians to follow evidence-based guidelines for care and rewarding them for making sure preventive services and screenings are a priority. They are concerned about diabetic screenings or recommended vaccinations. They have even started and maintained a pay-for-value program which is a total cost of care arrangement. It is supposed to empower physicians to strive for value by delivering services more efficiently across a tightly integrated continuum of care while closely managing costs. That sounds like the rhetoric associated with the HMO concept. Everyone knows HMOs do not provide quality care to anyone, regardless of the provider or the insurance marketing material.

Mr. Phillips believes that total cost of care programs offers the best shot at slowing the upward trajectory of medical spending because providers and insurers alike have a stake in containing costs for patients. He does not explain how because he cannot. How many physicians have you encountered expressed a sincere concerned about the cost of care to their patients? How many spend more than five to seven minutes with you and inquire about your out-of-pocket costs in that narrow window of time? By and large, physicians do not care about their patient's cost burden, they care about their reimbursement for caring for them from the insurance plan of which the patient is a member.

According to Mr. Phillips, BC/BS has put primary care providers at the center of their pay-for-value strategy because they "hold the keys to the preventive and coordinated care that can significantly improve quality of life." Again, these words are the same words I heard as a medical student in the 1970's. Back then, the primary care physician was the gatekeeper of services and had his/her reimbursement based on the reduction of services provided to the patient. The more the primary care physician accessed the healthcare system, the less they got paid since their payment came out of a lump sum for the disease-related group assigned to the patient by the insurance company. Just like trickle-down economics, this old, worn out, tattered and torn concept does not work; but it makes for great commentaries by profit-driven insurance companies.

BC/BS has spent about forty million dollars to create the pay-for-value initiatives. They have designed evidence-based quality benchmarks of care, such as prescribing statins to anyone who has an LDL-Cholesterol above 100 mg/dL. The benchmark was not created on data that was derived from double-blind placebo-controlled trials to evaluate the effectiveness of statins in preventing heart disease in patients who do not have heart disease; it was created to expand the market for statin use. Flu vaccination is another one of those benchmarks. This year, less than ten percent of the cases of flu can be impacted on some level by the current flu vaccine. It's essentially useless. But insurance companies and Medicare administrators desire eighty percent or more compliance with their desire to have their members vaccinated as well as the office and hospital staffs providing their members' care.

Standardized evidence-based quality benchmarks are another way of standardizing care to everyone regardless of the effectiveness of the care. In my practice, most the patients I evaluate for gastrointestinal problems have been to several occidental allopathic medical physicians qualified by the board of gastroenterology. They have had gastric endoscopy and colonoscopy at least once, if not twice or three times. Most of them have been told that their disease was functional (in their heads), and no medications could relieve them. These patients are routinely told that food consumption has nothing to do with their GI distress. Basic science research has shown food intolerances and mal-absorption syndromes cause gastrointestinal disease. But GI specialists refuse to acknowledge the newest information on diet-related illness. It is these same specialists that created the standard practice guidelines that BC/BS has implemented for gastrointestinal disturbances. The Rooster is in the Hen House.

In 1982, Australian researchers found that H. Pylori bacteria was causing stomach and duodenal ulcers. When they published their work, many of my faculty in medical school and residency denounced the idea as poppycock. Ulcer treatment was managed surgically. General surgeons removed parts of stomachs, cut the vagus nerve and surgically permanently opened the pylorus valve in the stomach to allow food and acids to pass freely into the small intestine. These surgeries did not work but were the standard practice at that time. It took twenty years for American physicians to embrace H. Pylori as the etiology of ulcer formation as well as treatment with antibiotics and antacids. The Australians won a noble prize for their work in medicine.

If we did not know that bacteria caused ulcers and we discovered that antibiotics could cure ulcers today instead of unnecessary and ineffective surgeries, would the insurance companies embrace new innovative research and change their reimbursement schemes? Absolutely not. They would label antibiotic treatment as experimental for ulcer treatment. And continue to herd people to the surgeons for definitive care. Most of the chronic unrelenting illnesses have no FDA approved treatments or evidence-based therapies that are effective. I'm not sure what BC/BS spent forty million dollars on, but I can assure you, that money should have been spent on patient care directly not initiatives that are re-inventions of the same ole insurance dogma.

The only way to provide patients better quality care is to provide better quality care, regardless of the reimbursement scheme. The idea that quality care can be enhanced and at the same time reduce the amount of money being paid for that high-quality service is absurd in today's world no matter how Mr. Phillips tries to spin the yarn. There is nothing preventing a healthcare insurance company handsomely paying experts in their fields of medicine to create a standard of care that will be cheap, ineffective and serve the economic benefit the specialists and insurance company, but not the patient.

We are experiencing these deplorable behaviors in pharmacy benefit management plans as well as healthcare insurance programs. BC/BS of Tennessee is trying to get ahead of the consumer backlash that is going to emerge because of their cost-cutting activities in 2018 and beyond. We need to keep them accountable. Right?

Just don't get sick anytime soon.



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