Don't expect a cost-saving fallout from Wellpoint's blended rates

LETTER — Posted Jan. 23, 2006

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Regarding "Higher coding spurs insurer to 'blend' pay rates" (Article, Dec. 26, 2005): AMNews did a great job at presenting nearly all of the concerns I share pertaining to blended pay rates from WellPoint Inc.'s Anthem Blue Cross Blue Shield of Ohio. However, there are a couple more things to add.

As insurance premiums and co-pays rise, patients' consumerism will rise naturally. America is the land of the biggie size and "getting your money's worth" is the goal. Ages ago, our practice decided to adhere to the adage that the customer is always right. In doing so, we do not ask the patient to return for each problem unless it is simply unreasonable or would compromise care.

Many appointments for colds become opportunities to do preventive care in addition to treating the patient-generated add-ons of depression, nerves, heartburn, chest pain, headache. As you might imagine, our profile skews toward level 4 encounters. However, this has been stable for nearly two decades and would not contribute to Anthem's current observations. Yet, we will experience financial loss and patients will lose convenience, consideration and service.

Obviously, physicians will change their approach to visits and will insist on "giving each problem appropriate time and attention." A mandatory follow-up appointment for each and every test result, therapeutic change and patient question, will "assure communication" and even "avoid medical mistakes." Whereas before, many minor therapeutic adjustments or trivial lab anomalies were courteously conveyed to patients via phone, at the cost of the physician. That respected the patients' time and co-pay expenses but, in addition, directly benefited the insurer in not incurring further visit costs. Luckily, physicians can assign the rational for such a change to our malpractice insurers and attorneys that propose phone medicine is inferior and that a face-to-face encounter is preferred.

Don't forget to include the watchdog groups demanding something be done to eliminate medical mistakes.

Slipping in an extra level 3 left open by the time voided by the level 4 may actually generate more income. In fact, it fits better into the philosophy of working smarter, not harder. Cheated by the change is the patient consumer who is seeking their money's worth or comprehensive care.

As to the pay-for-performance concept, this is a hoax. In dealing with some of the best statisticians and odds-makers in any industry, physicians haven't a chance. Insurers know just where to draw the line where most doctors will fall just short of any robust reward. If we do, the target will be conveniently moved. The insurers know that what patients do is not always a reflection of what physicians address, recommend and order.

If anything, this action will lead us toward a secondary health insurance crisis -- the shunned, undesirable, noncompliant client. As to generic medication use, what other industry is rewarded for using 17-year-and-older technology?

In closing, doctors will once again find their way through this new financial quagmire, but the true cost will be born by the consumer.

Mark D. Schmidt, MD, West Carrollton, Ohio

Note: This item originally appeared at http://www.ama-assn.org/amednews/2006/01/23/edlt0123.htm.

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