WCRI’s annual meeting concluded with a panel discussion reviewing the previous day and a half.
Following up on Dr Mueller’s excellent presentation about the coming changes in the health care system, Keith Bateman noted that while guidelines may help increase consistency, a percentage of providers won’t follow guidelines because they are just in it for the money. Bateman is right; I’d add the rather obvious observation that guidelines help payers, judges, and analysts determine which providers are ‘good’. That is, who treats consistent with best practices. I’d suggest that this may actually be the most important benefit of guidelines.
There was discussion earlier in the conference re the influence of fee schedules on utilization of health care services; Bateman said utilization is driven by claimants but also by payers themselves, for without treatment there is no claim.
Scarlette Gardner Esq. spoke about provider networks saying that the perception is the larger the network the more savings due to the network’s market share. She did note that there is some research indicating networks do not actually result in lower costs. Gardner said in fact physicians actually view networks as an intrusion and evidence that payers don’t trust them. Networks want lower reimbursement for what are usually higher cost patients, with costs defined as more work for the provider.
Makes sense to me.
It got worse for networks from there. Gardner noted that the ‘medical home’ can deliver better outcomes, and this model requires good communication among all parties yet networks have removed the payer from a direct relationship with the provider. The doc rarely answers to the insurer, but rather to the managed care vendor. She concluded by asserting that there is some evidence suggesting that the impact of discounted networks may include lower fees, but these fee reductions are overcome by increased utilization.
She summed up with a few words lauding fee schedules as one way to manage reimbursement. Her point was that fees in work comp should be fair in that work comp reimbursement should be competitive with other payers – the same services should be reimbursed at the same rates regardless of who is the payer.
I’d note that Ms Gardner works for the North Carolina Medical Society. Nonetheless I’d have to say her points are well worth considering.
Darrell Demoss of Medrisk made two excellent points. DeMoss noted that sometimes we err when we think that something is common because it is easy to think of examples of that ‘thing’ occurring. Specifically DeMoss says this happens when payers apply UR to providers, and gave as an example UR for physical therapy. The law requires payers to review all requests for more than six PT visits in Tennessee. I agree with DeMoss, The technique is not wrong, the application of the technique is just not appropriate in this instance.
Managed care as differently defined and applied in the fifty-one plus jurisdictions can be a blunt instrument – at best. The impact of networks – big, discount based, compendia of every live and some dead docs – has been of questionable value. Mandatory UR, and its opposite, the refusal to consider any utilization review, are both problematic. One drives up admin expense while the other makes it very hard to eliminate inappropriate care.
Note – this was posted via an iPhone, which although really cool, doesn’t allow me to use some features of the blogging software. I’ll clean it up later.
Nov
13
