The biggest issue for health care practices today, in my opinion, is their lack of control over their destiny. In a sense, perhaps, they never had any and any independence and mastery over their future were only illusory. However, it has become painfully obvious to me after almost 34 years in health care that this is the biggest challenge facing independent groups and independent physician associations today.
The payments, if they are part of managed care or accountable care, are often subject to the whims and fancies of the HMOs or CMS. Rules can be changed arbitrarily, retroactively, data can be changed or hidden or controverted as needed. Payments come months later, sometimes as late as 18-24 months. The small practices do not have the wherewithal to challenge these numbers, nor the ability to review them on their own. Thus, they are dependent on the health plans and CMS while being the true providers of service and the true producers of data, which is consumed by the payers or regulatory authorities.
PBMs are a complete joke. They pay one amount to the manufacturer and charge another to the insurance company. Part D expenses have layers within layers of commission and hidden charges. The cost of drugs goes up 13-15% every year and no one can lift a finger to address this issue. Recently, a health plan refused to share any bonuses and conveniently refuted its data it had shared over the last 12 months with us consistently over its portal. The CEO of one of the largest health insurers had no problem completely changing numbers and reducing benchmarks by 30% and when challenged he agreed to restore the reduction immediately.
Another CEO of a Fortune 100 health plan lied to us and facilitated the transfer of three providers from our network to another controlled by her health plan. All this done surreptitiously and illegally while flouting all professional relationships and etiquette. She broke her contract with an oncology network and denied having signed the agreement and, when confronted, conveniently apologized for her mistake while insisting on the legitimacy of her move.
This stinks and it is extremely painful to see providers at the receiving end of this collusive and collaborative systemic bias against them. What is the solution?
There is only one in my mind. Providers must get their act together, whether it is compliance, or operations, or technology, or financial planning. Providers have to manage their data, harness the new technologies like AI and RPA to improve efficiencies, network together to create more equitable contracts for their services, and create strong compliance and regulatory platforms to improve their earnings and safety.
Providers have to control their destiny, and this can only be done when they are no longer producers of data but also its consumers and managers, controllers, and appraisers. Then, and only then, will they have the financial and legal ability to take on the emerging forces arraigned against them and can bring greater value for their ‘low premium services’.