The Nightmare of Health Insurance Bureaucracy

Douglas Arnold, CEO of Medical Professional Services in Middletown, CT, a clinically integrated independent practice association of 400 physicians, and I were talking over the weekend.

He's a Jersey Boy, like me, and he was recounting back in the day when he was a teenage running back for Nutley High, in the shadow of New York, and had helped his team beat nearby powerhouse Montclair High, which had a 30-plus game winning streak at the time. Arnold is still on the offensive–and last week in a talk before the American Medical Association, he talked about the health plan bureaucracy as "daunting" and an "administrative nightmare"—a seeming opposing team. He says payers and providers should be on the "same team" and develop pilot programs, but health plans sometimes get in the way.

Specifically, Arnold discussed a shared savings plan he's working on in Connecticut with his own medical group, another medical group, and a large insurer. He says they have been working on the plan for 18 months and it's been continually dragged out in a corporate bureaucracy, with payers sharing a good part of the blame.

As the Center for Healthcare Quality and Reform describes it, shared savings is fairly simple and benign: if a healthcare system or provider reduces total healthcare spending for its patients below the level that the payer (Medicare or private health insurance plan) would have otherwise expected, the provider is rewarded with a portion of the savings. The idea being that the payer still spends less than it would otherwise, and the provider gets more revenue than it would otherwise, according to the Center for Healthcare Quality and Payment Reform.

In the Connecticut pilot program, a group of physicians are discussing with payers a plan that is focused on avoidable emergency room visits, Arnold says. Besides Arnold's group, the other group involved is the Connecticut Academy of Family Practice, working on behalf of a group of primary care doctors.

"We are trying to create "care teams" of [primary care physicians] in specific markets that would share patient information, keep their practices open late, such as 9 p.m. or on weekends on a rotating basis to provide patients with a viable after-hours alternative to going to the ER for primary care," Arnold says. "The plan is for the payer to pay doctors a per-member per-month member fee as well as management and evaluation fees for care given "after hours" he says.

The plan is to offset avoided emergency visits. The medical groups would share patient data through EHRs (electronic health records) and Web-based IT solutions, according to Arnold. Many emergency room visits, are, as Arnold puts it, "very costly" and often result in unnecessary actions, such as imaging or even hospital admissions.

Like many other pilot programs, the Connecticut project was seen as exciting and innovative. For a year and a half, the physician groups have gotten around the table discussing the plans with a large insurance, which Arnold asked not to identify.

"We want to encourage these physicians to get integrated because a lot of this money gets wasted in an emergency room," Arnold says. "Shared savings is a way to generate savings off most hospital services or diagnostics."

As Arnold puts it, and I agree, the Connecticut discussions have a goal to generate savings—and that is what healthcare reform is all about.

The plans look good, but reality sometimes bites.

"It sounds good in concept, but the administrative hassles of setting it up and getting [payers] to corporate ‘buy in' are daunting," says Arnold.

After 18 months of working, "We are still waiting for the final OK," Arnold says with frustration.

In the meeting with the AMA, Arnold told of "substantial problems with payer legacy IT systems—such as how to code management fee and bonus payments—especially for large, self-funded employers who have existing fee-for-service contracts based on medical clams and a fixed administrative payment to plan."

Because of the need for flexibility in IT and other aspects of making the pilot program work, negotiations also have been flexible—on the local level, Arnold says. However, when the project "has gone up to the executive suites, it's been stalled," he says.

But Arnold has tried to go behind the curtain and see the problems through the payer's vantage point.

"The biggest hangup for the payer has been how to administer and how to pay for it," he says. "How do you bill self-funded employers for a PCP (primary care physician) management fee when their contract is based on claims paid?"

A lot of these new payment methods are really difficult to administer, Arnold says, "It's an academic exercise without significant payer involvement and support."

"It has become an administrative nightmare," he says. The payers, he told the AMA, "seem so risk adverse."

Insurers would have likely been the proverbial fly on the wall during Arnold's talk in DC last week. Arnold spoke from experience and frustrations. Health insurance companies can learn from Arnold and the Connecticut program and understand that they will have to remove these kinds of barriers if the two sides are to work together.