BCBS getting rid of docs who cost too much

[Pain Applicant1]

I have BCBS as my insurance provider. They just sent me a letter saying that they're going to change the docs in my network to those who only provide more cost efficient care.

It will be interesting to see how this turns out with respect to us on the provider side.

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[powermd]

Makes sense when I look at the cost data for the med lists prescribed by docs I do P2P with. They seem to think nothing of prescribing a med that costs $20K/yr and provides next to no benefi (that would be oxycontin in the case I'm thinking of, btw). I love confronting them with cost data. The insurer should just dump the doc.

I have BCBS as my insurance provider. They just sent me a letter saying that they're going to change the docs in my network to those who only provide more cost efficient care.

It will be interesting to see how this turns out with respect to us on the provider side.

 

[dc2md]

I think that's a great idea. It's the overutilizing schmucks that are ruining it for the rest of us.

 

[PinchandBurn]

I think that's a great idea. It's the overutilizing schmucks that are ruining it for the rest of us.

be careful what we wish for.

Who gets to determine who's an overutilizer? What's their criteria? Do you want paper pushers dictating medical care?

I would be guarded about this....

 

[Disciple]

I have BCBS as my insurance provider. They just sent me a letter saying that they're going to change the docs in my network to those who only provide more cost efficient care.

It will be interesting to see how this turns out with respect to us on the provider side.

This has been standard practice for many workers comp insurers.

Helps to control costs in competitive regions.

 

[loveoforganic2]

I have BCBS as my insurance provider. They just sent me a letter saying that they're going to change the docs in my network to those who only provide more cost efficient care.

It will be interesting to see how this turns out with respect to us on the provider side.

How does BCBS measure outcomes such that they can look at cost efficiency?

 

[hyperalgesia]

How does BCBS measure outcomes such that they can look at cost efficiency?

They use a complex formula: Outcome efficiency = 1/cost
Insurance companies are not qualified to be watchdogs.

 

[pastafan]

How does BCBS measure outcomes such that they can look at cost efficiency?

Being cynical, I don't believe that outcomes are truly part of their equation. If outcomes such as surgical and chronic disease management are good then total costs will be lower with fewer hospital admissions, shorter LOS, few re-ops. Pain on the other hand is much cheaper to "treat" with oxy, benzo, and muscle relaxants than procedure based therapies. Combine this with patients dying from overdoses and the insurers' cost to treat drop substantially.

 

[clubdeac]

The major pain organizations (ASIPP/ISIS) should be determining reimbursement and coverage based upon the most up to date practice guidelines. We as physicians are the only ones qualified to do this. I definitely don't agree with the standard of care being dictated by paper pushers who are only interested in the bottom line. Pinch is right

 

[Ducttape]

they are using this to try to get doctors to order less while they portray themselves as the keeper of the public good.

its a publicity ploy on the their part -

We are going to save you money, by making sure your doctors provide cost effective medicine!! this is a win-win for you!!
oh and btw, the reason your copays and deductibles went up is because of these doctors are lining their pockets with oodles of your dough!!

(Sent from my iPhone - location: back seat Bentley).

 

[geauxg8rs]

I had a new patient recently say that she checked with her insurance company about me prior to her visit. She says they told her I was one of the best doctors around. Hilarious. How would they know anything about the quality of physician?
Why would you ask your insurer about physician quality?
It made me think that cheapest=best. I immediately wanted to switch all scripts to brand name only and start doing series of 5 injections so as not to be an outlier. Outliers are bad in
Medicine today.

 

[stim4u]

united medicare is dropping physicians as well in my state.
It made it to the newpapers and under investigation.
Interesting what will happen with insurances determining who will see patients.
lovin' obamacare....hopefully ductappe/soc/and lonebo don't get dumped soon...

 

[SSdoc33]

united medicare is dropping physicians as well in my state.
It made it to the newpapers and under investigation.
Interesting what will happen with insurances determining who will see patients.
lovin' obamacare....hopefully ductappe/soc/and lonebo don't get dumped soon...

hey, i think obamacare is train wreck. i thought we should have gone single payor the whole time. im guessing the crowd does not agree.

as far as physicians getting dropped, i do think there is reason for concern. it wont cut out "only the bad apples" who do a series of 3 on everyone. it could cut out anyone who doesnt just order cheap MS contin and hydrocodone for everyone. or those who want MRIs before an epidural. or those who perform multi-level RFs. insurance will ONLY look at cost of care, rather than quality, as there really arent good and standardized quality measures in our field.

 

[Ducttape]

united medicare is dropping physicians as well in my state.
It made it to the newpapers and under investigation.
Interesting what will happen with insurances determining who will see patients.
lovin' obamacare....hopefully ductappe/soc/and lonebo don't get dumped soon...

dont get me wrong. i am not "for" obamacare or anything managed by the current Medicare czar.

imho, the main culprits in the health care disaster are 1. insurance companies 2. insurance execs 3. greedy hospital systems 4. big pharma 5. device companies.


Obamacare addresses NONE of these.


the main victims are people with no insurance and us health care providers.


the best system would be one run by non-profit insurance companies - well, more like a charity organization - that truly had the best interest of their patients in mind, who were not fixated on the dollar, that is affordable enough for everyone to get some amount of health care insurance, so they dont go broke if they have get care.


my daughter recently broke her elbow. total cost for a supracondylar fracture thus far is over $5000. that could bankrupt almost anyone already living on the margin, like 50% of Americans...

 

[Louisville04]

Pain on the other hand is much cheaper to "treat" with oxy, benzo, and muscle relaxants than procedure based therapies. Combine this with patients dying from overdoses and the insurers' cost to treat drop substantially.

as far as physicians getting dropped, i do think there is reason for concern. it wont cut out "only the bad apples" who do a series of 3 on everyone. it could cut out anyone who doesnt just order cheap MS contin and hydrocodone for everyone. or those who want MRIs before an epidural. or those who perform multi-level RFs. insurance will ONLY look at cost of care, rather than quality, as there really arent good and standardized quality measures in our field.

the best system would be one run by non-profit insurance companies - well, more like a charity organization - that truly had the best interest of their patients in mind, who were not fixated on the dollar, that is affordable enough for everyone to get some amount of health care insurance, so they dont go broke if they have get care.


my daughter recently broke her elbow. total cost for a supracondylar fracture thus far is over $5000. that could bankrupt almost anyone already living on the margin, like 50% of Americans...

Would a year supply of oxycontin cost more than a set of three lumbar ESI's done in the office?

The $5000 was your cost after insurance paid?

 

[loveoforganic2]

They use a complex formula: Outcome efficiency = 1/cost

That'd be about in line with what I'd figure

Being cynical, I don't believe that outcomes are truly part of their equation. If outcomes such as surgical and chronic disease management are good then total costs will be lower with fewer hospital admissions, shorter LOS, few re-ops. Pain on the other hand is much cheaper to "treat" with oxy, benzo, and muscle relaxants than procedure based therapies. Combine this with patients dying from overdoses and the insurers' cost to treat drop substantially.

Even within the realm of surgical and chronic disease management, I would be surprised if they take a serious look into outcomes. That's why I was surprised by the initial mention of cost efficiency. I would be surprised if they do any legitimate analyses along those lines.

dont get me wrong. i am not "for" obamacare or anything managed by the current Medicare czar.

imho, the main culprits in the health care disaster are 1. insurance companies 2. insurance execs 3. greedy hospital systems 4. big pharma 5. device companies.


Obamacare addresses NONE of these.

Thinking offhand, doesn't the ACA imposes (A) limits on what payers can use toward non-healthcare areas, (B) require community rating, (C) disallow payers to drop individual's insurance, (D) remove lifetime caps on payer disbursement, and (E) incentivize ACO's?

As I see it, A, B, C and D attempt to address 1 and 2, and E attempts to address 3. I think 4 and 5 were deliberately neglected for political reasons (for the time being). The ACA seems sloppy to me, but it seems like it's making strides in some of the areas you say it isn't. I welcome clarification though

 

[bedrock]

That'd be about in line with what I'd figure



Even within the realm of surgical and chronic disease management, I would be surprised if they take a serious look into outcomes. That's why I was surprised by the initial mention of cost efficiency. I would be surprised if they do any legitimate analyses along those lines.



Thinking offhand, doesn't the ACA imposes (A) limits on what payers can use toward non-healthcare areas, (B) require community rating, (C) disallow payers to drop individual's insurance, (D) remove lifetime caps on payer disbursement, and (E) incentivize ACO's?

As I see it, A, B, C and D attempt to address 1 and 2, and E attempts to address 3. I think 4 and 5 were deliberately neglected for political reasons (for the time being). The ACA seems sloppy to me, but it seems like it's making strides in some of the areas you say it isn't. I welcome clarification though

Obamacare does a poor job addressing 1-3, and yes it does ignore 4 & 5 which are responsible for as much of the costs as 1-3. A much higher % of healthcare dollars ares spent on the increased of perpetually trademarked drugs and medical devices that cost 20X what they do in other countries than on anything else in healthcare.

They do something about that and I'd vote for it. Until then, you're just wasting money and punishing physicians

 

[loveoforganic2]

Obamacare does a poor job addressing 1-3, and yes it does ignore 4 & 5 which are responsible for as much of the costs as 1-3. A much higher % of healthcare dollars ares spent on the increased of perpetually trademarked drugs and medical devices that cost 20X what they do in other countries than on anything else in healthcare.

They do something about that and I'd vote for it. Until then, you're just wasting money and punishing physicians

I don't disagree, though I think a lot of the decisions made weren't failures in devising an appropriate system, but rather political strategy to fit in as much as possible while still getting the bill passed. With it passed and implemented, it's much easier to continue toward a stronger system with incremental reform (and much easier to implement price control if people buy into the system). As far as pharma and medical devices, lobbying and greed prevail there.

 

[stim4u]

here is a very good article about the complexities of obamacare and how the insurance companies will manipulated it for their best interest. They will be penalized for making profits, rewarded for not pushing for younger payor mixes, cutting physicians, and other misguided repercussions of ACA. The dropping of doctors is a scary thought for physicians and patients alike. This plus the 10-15K deductibles and 'subsidized' premiums are a middle finger by the Insurance companies to society and the Obama administration... this is only going to get worse, called the 'death spiral'...

http://www.bloomberg.com/news/2013-10-23/why-obamacare-is-like-three-mile-island.html

 

[axm397]

United healthcare just sent my group a letter that some of our doctors did not qualify for their "gold star rating" for cost effectiveness although all of us did qualify for their "quality" rating - so those who didn't meet their cost effectiveness criteria would be non- gold star, meaning patients will have to pay a higher copay ($80 vs $50) to see those doctors. The crazy thing is they didn't tell us how they judged this. The doctors they singled out were very different and really are not very heavy utilizers of expensive diagnostics or treatment options... We are going to appeal and find out more. This is just the beginning.....

We've been getting notification for the last few years if we are considered "outliers" in terms of our E&M billing level - regardless of our documentation and how much time we spend with the patient, etc. Humana flagged me last year for "overutilizing" MRIs - cited 3 cases where they thought it wasn't necessary - and made me go through P2P for EVERY MRI I ordered for a period of time. I reviewed all 3 cases - one was a r/o fracture in the thoracic spine in a morbidly obese patient s/p fall with hx osteoprosis and i documented that xray was subpar because of habitus and the bone density, one was a shoulder MR arthrogram in a patient that failed conservative management (PT, injection by ortho, NSAIDs, etc.) x 6 months that ended up needing a scope (which they approved and paid for), and the last was a rule out tumor in a patient with known history colon Ca with night pain and weight loss. Every time I called for a so called peer to peer, I got a nurse or a "clinical specialist" who didn't care about malignancy risk, didn't care about trauma, didn't care about numbness, and didn't care about reflex change - all they cared about was how long the patient had pain (they wanted to see >6 wks not a day less). i contemplated just not seeing Humana patients.

 

[stim4u]

your practice is going to have to roll with it...
3K doctors just dropped from United Medicare Advantage programs in my state.
you patients will have to change their policies.
you can thank our con-artist president for this bs....