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Take Action with Insurance
& Network Management Companies . . .
Challenge YOUR insurance
company (and network management company) to co-create more ethical
health partnership with both patients and physicians! And tell
your family and friends to do the same!
Changing injustice is not
done with one letter. Write one. But as you read about issues
and learn how important it is that we take back healthcare NOW,
we hope you will make time to respond to their responses, to
write others, and take other actions.
Note:
If your insurance company
uses a network management company, write them also when you address
physician reimbursement and doctor/patient relationship issues.
Your insurance company will try to tell you that it is up to
the network management company to set physician fees and that
is partly true. But it is important to also hold the insurance
company accountable since they support those fees and policies.
(I suggest you either
send your state insurance commissioner a copy of your letter
or write another one specifically to him/her. We will be creating
a page of contact information for state commissioners.)
REMEMBER . . . .
As you write these letters, people,
companies, government officials, will try to give you a canned
response or brush you off. Don't settle for that. Write AGAIN
in response to their letter. They WANT us to give up. Yes, it
takes energy and effort on your part. But remember, it is YOUR HEALTHCARE that is at stake and it
is high time we take it back
and hold ALL parties (including ourselves) ACCOUNTABLE for both
the problems AND for creating a solution.
KEEP YOUR LETTER AN EXAMPLE
OF ETHICAL PARTNERSHIP:
Keep your tone respectful and yet, be clear in your concern and
what you want. Work to present the facts as best you can and
state clearly your desire to call them and all others who impact
healthcare into more just relationship with you and your physician.
While insurance companies are not the WHOLE problem, they contribute
significantly to the problem and that is what you are asking
them to be accountable for and to change.
Major
Insurance Company List with Contact Information
SUGGESTED POINTS TO MAKE
IN YOUR LETTERS: (see more at
Negotiations)
1. YOU EXPECT THEM TO CREATE
MORE ETHICAL HEALTH PARTNERSHIPS WITH PATIENTS AND PHYSICIANS.
2. YOUR HEALTH INSURANCE
PREMIUMS CANNOT CONTINUE TO INCREASE AND WHY.
3. PHYSICIAN CONTRACTS,
REIMBURSEMENT AND NEGOTIATION METHODS MUST BE FAIR.
WHY FAIRNESS TO PHYSICIANS
MATTERS TO YOU AS A PATIENT:
A) It matters to you because it is what is ethical and just.
You do not want to be a silent party to injustice.
B) You want your medical decisions and care to be in the hands
of you and your physician, not a 3rd party financial company.
C) When insurance companies do not pay physicians adequately
several things can happen that impacts your care as a patient:
1. Physicians restrict services or close practices.
That affects YOUR access to quality care.
2. Some physicians try to see more patients
to make up the income so they can stay in practice. That affects
the quality of your care, your satisfaction, their satisfaction
AND your safety.
4. SUMMARIZE AGAIN AT THE
END WHAT YOU WANT, invite or challenge them to ethical partnership
with both patients and physicians and tell them you expect a
response.
5. Put at the bottom of
your letter CC: and list the names of people you are sending
copies of your letter
Here are more details to
help inspire your thinking as you write your letters:
1. YOU EXPECT THEM TO CREATE
MORE ETHICAL HEALTH PARTNERSHIPS WITH PATIENTS AND PHYSICIANS.
Invite, call, challenge your company to co-create more ethical
health partnerships with patients and physicians. Ethical health
partnership includes fairness, justice, regard for the well-being
of patients and their physicians, for quality care, for patient
safety, and for strengthening the physician/patient relationship
as the core of healthcare. Ethical health partnership also means
that while companies need to make a profit, it is unacceptable
to you to have them make profits at the expense of patients and/or
physicians. Let them know that this is an issue for YOU, the
patient.
When you can find a statement
of mission, vision or values on the company website, relate your
points to those values that they claim guide their actions. Tell
them you want them to act in a way that has integrity with those
values.
2. YOUR HEALTH INSURANCE
PREMIUMS CANNOT CONTINUE TO INCREASE:
Health insurance premiums
have doubled and sometimes tripled over the past 5-7 years. You
are tired of it. Projections show that insurance premium rates
will continue to increase at a rate that far outpaces increase
in worker's wages. (Milliman's Inter-company Rate Survey states
that HMOs are expected to raise premiums for renewals up to 15%.
Between 2002-2003 premiums increased 13.9% while the health plans
payments for medical costs increased only 9.6%. Managed Healthcare
Executive reports that the rates have gone up 11.2% as of
October, 2004. They put that into perspective by noting that
the rate of inflation in the same time period has been only 2.3%
and the rise in worker's earnings were only 2.2%.)
Increasing rates continually add to the number of uninsured as
more and more people cannot afford the increasing premiums. (Is
it possible that YOU will not be able to afford it in the next
few years?) Express your concern. Encourage them to address the
root problems instead of easy surface issues.
3. PHYSICIAN CONTRACTS,
REIMBURSEMENT AND NEGOTIATION METHODS MUST BE FAIR:
There are 2 basic parts to contract issues.
A. As part of a 'take it or leave it' approach that insurance
and network management companies assume, physicians are stuck
with clauses in their contracts that impact medical decision-making,
referral to specialists, limiting treatment options and more.
Decisions affecting your diagnosis, treatment, and care belong
with the physician/patient relationship, not with insurance or
network management companies.
B. Insurance companies have been
decreasing physician payments (up to 30% over the past 8-10 years)
WHILE YOUR premiums are sharply increasing. It is unjust that
a physician would be paid today, less than what Medicare would
have paid him or her for the same procedure in 1995. That is
what happens every time a surgeon does gallbladder surgery, or
removes hemmorhoids. Cheating physicians out of their fees is
unjust. . . . especially when not only the cost of living is
increasing, but so is practice expense. Malpractice rates are
skyrocketing. Many insurance companies say that they set fees
based on work involved, practice expense, and liability risk.
Yet, while risk has gone up and practice expense has gone up,
reimbursement has gone down. Physicians are being squeezed out
of practice. Paying fair fees is not the driving force behind
rising health care costs. As physician rates have gone down,
costs continue to climb steadily. Insurance companies are not
addressing the core driving forces of higher costs. Instead they
are targeting the 'easy' approaches to saving money which is
unjust to patients and physicians and ultimately creates more
problems.
Let them know you expect your
insurance company, which you are paying, to pay just fees to
physicians and to create fairer negotiation policies with physicians.
A physician in solo practice or even small groups have essentially
NO negotiating power with insurance or network management companies.
(See quotes from one network management
report below) Let the company know you want them to create
fairer methods of negotiation.
WHY FAIRNESS TO PHYSICIANS
MATTERS TO YOU AS A PATIENT:
A) It matters to you because it is what is ethical and just.
You do not want to be a silent party to injustice.
B) You want your medical
decisions and care to be in the hands of you and your physician,
not a 3rd party financial company.
C) When insurance companies do not pay physicians adequately
several things can happen that impacts your care as a patient:
1. Physicians restrict services or close practices. That affects
YOUR access to quality care.
More and more physicians are reducing services that have excessively
reduced fees and considerable liability risk. Some physicians
are retiring early, not because they want to, but because they
have to. Others are simply closing their practices or moving
to other states that make practice more financially feasible.
(This is especially true if you are in one of the 'crisis' states
like Florida, Pennsylvania and more.) It is NOT ONLY a malpractice
rate problem, although that is certainly a huge problem. It is
the combination of malpractice and REDUCED REIMBURSEMENT that
makes it harder and harder for physicians to keep their practices
going.
2. Some physicians try
to see more patients to make up the income so they can stay in
practice. That affects the quality of your care, your satisfaction,
their satisfaction AND your safety.
If physicians are having
to rush through patients, there is more chance of error. The
financial pressure from insurance companies creates a climate
where MORE error is likely to happen. In addition, squeezing
in clients and rushing through damages the physician/patient
relationship which impacts quality of care and satisfaction.
In an effort to make quick decisions and be efficient, rushed
doctors are less likely to allow you the important role of asking
questions and fully discussing your condition or your care. That
is not good for either of you!
4. SUMMARIZE AGAIN AT THE
END WHAT YOU WANT and tell
them you expect a response and want to know how they plan to
address your concerns. You can issue them an ethical challenge
like the one here, or
suggest other actions (see a list of some here.) Write
us with ideas and suggestions that you have.
5. Put at the bottom of
your letter CC: and list the names of people you are sending
copies of your letter. (Include
all the top level management, if you have names and any boards
of the company. Some others you might want to consider are: your
state's insurance commissioner or comptroller, your governor,
state legislators. You might also want to send a copy to your
physician . . . it might make his or her day! At the very least
it lets our physician's know that we are taking an active role
in OUR efforts to co-create an ethical health partnership with
THEM as well.)
TYPICAL INSURANCE COMPANY
RESPONSES: (Don't let them brush you off!)
1. They will tell you that health costs are increasing and they
have to contain costs. Sometimes companies will try to lead you
to believe that if they are fair to your physician, it will cost
you more as a patient. Trying to make it an either/or situation
is inaccurate AND it is a way to weaken patient/doctor partnership
and power. Respond by reminding them that health insurance company
profits are higher than they have been in 10 years, that executive
pay is excessive when they are acting in ways that create harm
to patients and physicians, and that it is NOT physician pay
that raises fees (especially since as physician reimbursement
has gone down, premiums have gone up!) (What causes higher costs
are things like technology, hospital costs, and increasing chronic
illnesses in patients (many of which are due to unhealthy lifestyles.)
Challenge them to think and act creatively to address the REAL
health cost problems instead of trying to take an easy bandaid
approach which is cutting physician fees or raising patient premiums.
By doing that, they shoot themselves in the foot since they will
have less providers and less patient customers!
2. They will tell you repeatedly
that your physician has agreed to those fees and/or that they
have negotiated those fees with your physician. Ask them about
their negotiation process. (Most times they simply present their
plan to physicians, tell them how many plan members they have,
and the physician either takes it or leaves it. If the plan is
large, physicians can't afford to NOT be a part of it, so they
are over a barrel. Let the insurance company know that YOU know
that physicians cannot join together as group to negotiate anything
with an insurance company. They are bound by anti-trust laws
(and insurance companies are exempt and that you and others will
be seeking to change that imbalance of power.) That means an
individual physician or a small group has NO leverage with a
large company. There is no real negotiation. (This is also true
when physicians try to get insurance companies to change contractual
issues that sometimes compromise your care as a patient. In all
these, physicians have no leverage or power in the negotiation.)
That is part of the injustice.
Here
is an example of what one of the largest network management companies
brags about in their annual report:
"Our unsurpassed growth equals power. As more customers
choose PHCS as their health care cost management partner, we
leverage the strength of their 15 million members to achieve
the best savings in the industry. . . . we enjoy a very powerful
position in the industry. . . ."
When talking about their fixed fee
approach:
"Providers, on the other hand, request straight discounts
or discount off of billed charges. . . .we are witnessing a growing
trend as an increasing number of providers are threatening to
terminate from our network if we do not accept new financial
arrangements arrangements that are not in the interest
of our customers Our position is to refuse to negotiate under
the threat of termination." (Note:
this company's 'customers' are insurance companies and employers).
"Milliman USA projected a composite unit cost increase
of 7.4% for inpatient, outpatient, physician and ancillary services
in 2003. While other health care organizations may accept a 7.4%
increase as an unavoidable component of today's health care environment,
we recognized that . . . we needed to set more aggressive goals.
We challenged our contracting staff to keep cost increases far
lower than the projected trend and they succeeded.
. . . (and) . . . enabled us to keep average composite unit costs
to just 2.6%."
(Since this included hospital inpatient
costs, and hospitals have more negotiating power than individual
physicians, I am curious how much physicians were squeezed in
this 'negotiation' process.
Tap the Power 2003 report.
I have not yet found a financial report for this company
that shows their profit margin. If anyone finds it, let us know!
Don't let companies brush you off.
Use your voice and your power as patients and physicians in partnership.
Related Resources and Actions:
Also see Reimbursement Section
on This Site for more info
Ethical Health Partnership Challenge
to Insurance
Lawsuits
Against Insurance Companies for
Unethical Behavior Toward Physicians
Insurance Company Addresses
or Links
Insurance
Commission links
What Physicians Can Do
(coming soon)
As always, I welcome your constructive
comments and suggestions about the material on this website and
how we can all be most effective in co-creating the kind of healthcare
system we all want. E-mail me at ideas@ethicalhealthpartnerships.org
© Dawn Lipthrott,
Ethical Health Partnerships, 2005 www.ethicalhealthpartnerships.org
(May be copied and distributed
as long as this identifying information is retained on copies.)
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