Delegates back collecting fees from patients at point of service

The AMA also calls for insurance companies to eliminate lifetime maximums for insurance drug benefits.

By Kevin B. O’Reilly — Posted Nov. 28, 2005

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Dallas -- Consumer-directed health plans such as health savings and health reimbursement accounts are supposed to be a new way of doing business, but some health plans are letting old habits die hard by requiring that physicians bill patients rather than collect fees at the point of service.

Physicians say they should be able to have patients pay before they leave the office, and at the American Medical Association Interim Meeting in November, the House of Delegates adopted a resolution that opposes any health plan requirements that say a physician must bill a patient for out-of-pocket payments.

The policy change stems from a Council on Medical Service report presented at the meeting that identified billing for services under consumer-directed health plans as a problem area. Some insurers offering HSAs, for example, "prohibit collection of payment from patients at point-of-service, instead requiring submission and adjudication of claims prior to the billing of patients," according to the report presented by council Chair Joseph P. Annis, MD.

These practices could add to administrative costs and prevent physicians from offering discounts for cash payments and, more generally, control how they price for services paid out of pocket, according to the report. Some plans do not even allow physicians to withdraw funds directly from a patient's checking account via a so-called smart card.

The house also directed the AMA to support "rigorous research" on the impact of consumer-directed health plans on physicians' practices and on patients' use of effective preventive care. HSA critics long have argued that high-deductible health plans would discourage patients from seeking appropriate preventive care, leading to worse health outcomes and higher health care costs in the long run.

Consumer-directed health plans "put a lot more power in the hands of consumers," said Ronald M. Davis, MD, an AMA trustee and an East Lansing, Mich., preventive medicine specialist. "We hope that they will be educated and make good use of health care resources. Sometimes patients only pay attention when they need acute care. We need to make sure people are following recommendations on screenings, getting exercise and not smoking."

Dr. Davis said "it's too early to tell" what impact, if any, the increasingly popular consumer-directed health plans have had on patients' use of preventive care, and that's precisely why the AMA is going to study the matter.

Specialty drugs

In other action, the AMA adopted new policies asking health insurers to be absolutely clear about how they will cover specialty drugs and to eliminate lifetime maximums on drug benefits.

New specialty drugs developed to treat a range of chronic and serious conditions, such as cystic fibrosis, multiple sclerosis, hemophilia and cancer have been covered by third-party payers. But it is often done in a way that's frustratingly unclear to patients and physicians. In response, the AMA adopted a new policy supporting "complete transparency of health-care coverage policies" for these specialty drugs, including the co-insurance and co-payment levels and how they are determined.

Another policy, which sparked debate among delegates, states that "employers and health insurers should eliminate the lifetime maximums on health insurance benefits" for specialty drugs. Some at the meeting suggested that the benefits be "sufficient to guarantee a reasonable level of coverage throughout the policyholder's lifetime." They believed that calling for outright elimination would greatly increase carriers' costs and make insurance less affordable.

But a majority of delegates said that language gave insurers too much wiggle room and adopted the measure to eliminate lifetime maximums.

Delegates did refer one resolution that touched on another aspect of consumer-directed health care for further study: physicians' and patients' access to allowable payment information. In August, Aetna made available to HSA patients the fees it negotiated with 5,000 primary care and specialist physicians in the Cincinnati area. Proponents of consumer-directed health care say it's this kind of pricing openness that ultimately will allow patients to choose not only on the quality of care but on price as well.

The resolution called for the AMA to advocate that health insurers make "allowable payment amounts" available to enrolled patients and physicians via a password-protected Web site. Several delegates opposed the measure, saying the information eventually would leak out to other insurers and weaken physicians' negotiating position. The house voted 445-27 to refer the matter for a report back at the June 2006 Annual Meeting.

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