opinion

10 things health insurers must do to regain trust

The AMA, with endorsement from 68 state and medical specialty societies, outlines steps health plans must take to be credible in the eyes of physicians and patients.

Posted June 14, 2010.

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A Harris Interactive poll late in 2009 asked the public which industries were "generally honest and trustworthy." Seven percent of respondents named health insurance companies, only slightly more than named oil companies and tobacco companies.

Even someone who has never had to struggle with a claim would be justifiably suspicious of insurers, given the barrage of news stories about the industry: ill-timed and massive premium hikes; rescission of coverage for the sick; and decisions to spend billions of dollars in stock buybacks instead of on health care. Meanwhile, insurer CEOs reap sky-high salaries and bonuses.

As American Medical Association President J. James Rohack, MD, put it recently, "The health insurance industry has a crisis of credibility."

He spoke those words May 24 as the AMA released its national Health Insurer Code of Conduct Principles. The code is a call for change from the medical profession, which witnesses, on a daily basis, what's right and wrong with the insurance industry.

The code sets forth 10 principles that govern both the business and the clinical operations of health plans. By following these principles, also endorsed by 68 state and specialty medical societies, health insurers can help create a more efficient, patient-centered health system -- and repair the damaged trust in their industry.

The code advocates for:

  • Prohibition of cancellation or rescissions of policies because of innocent mistakes on an application, or because a policyholder got sick or injured, or because insurer employees or contractors get bonuses for rescissions.
  • Fair and transparent pricing and accounting of health insurance premiums, with the "substantial bulk" of the money spent on care.
  • Clear and transparent access to medical care, meaning benefits that are available to all enrollees on a timely and geographically accessible basis at the preferred, in-network rate, and easily accessible physician directories that mark those doctors who are out-of-network or only available in a tiered plan.
  • Respectful relations by plans with their enrollees, physicians and other partners, including fair contracting, protection of patients' medical information and "appropriate deference" to the physician's skill and judgment.
  • Medically necessary care defined by what a prudent physician would provide in a certain situation -- rather than a definition for the economic benefit of health plans.
  • Clear information on benefit restrictions to the patient and the physician, with benefits based on clinically appropriate medical guidelines.
  • Elimination of complexity and confusion from health plan processes and communications.
  • Physician profiling systems that use good and relevant data to focus primarily on the quality of care -- not on reducing the cost of care.
  • Health insurers to conduct their business with "the highest levels of corporate citizenship," including complying with the letter and spirit of all laws affecting clinical and business operations.
  • Health insurers to pay claims accurately and on time, and to provide clear explanations of how each claim was handled -- as well as providing fee schedules, claim edits and pay policies that are disclosed and easily available.

More than a decade ago, health plans, through their national trade association, put out a code of conduct that pledged adherence to "high standards of quality and professional ethics, and to the principle that patients come first." Clearly, those patients and, it's safe to say, most observers, would not agree that is being followed.

Ten principles makes for a considerable list, but that is in line with how far the public has said the industry has to go to gain the trust of those it serves.

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External links

AMA Health Insurer Code of Conduct Principles (link)

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