Ethical Health Partnerships

  SUGGESTED POINTS FOR INSURANCE COMPANY LETTERS

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Dawn Lipthrott, LCSW
Ethical Health Partnerships
1177 Louisiana Ave. #212
Winter Park, FL 32789

 

Take Action with Insurance & Network Management Companies . . .



Challenge YOUR insurance company (and network management company) to co-create more ethical health partnership with both patients and physicians! And tell your family and friends to do the same!

Changing injustice is not done with one letter. Write one. But as you read about issues and learn how important it is that we take back healthcare NOW, we hope you will make time to respond to their responses, to write others, and take other actions.

Note:
If your insurance company uses a network management company, write them also when you address physician reimbursement and doctor/patient relationship issues. Your insurance company will try to tell you that it is up to the network management company to set physician fees and that is partly true. But it is important to also hold the insurance company accountable since they support those fees and policies. (I suggest you either send your state insurance commissioner a copy of your letter or write another one specifically to him/her. We will be creating a page of contact information for state commissioners.)

REMEMBER . . . .

As you write these letters, people, companies, government officials, will try to give you a canned response or brush you off. Don't settle for that. Write AGAIN in response to their letter. They WANT us to give up. Yes, it takes energy and effort on your part. But remember, it is YOUR HEALTHCARE that is at stake and it is high time we take it back and hold ALL parties (including ourselves) ACCOUNTABLE for both the problems AND for creating a solution.

KEEP YOUR LETTER AN EXAMPLE OF ETHICAL PARTNERSHIP:
Keep your tone respectful and yet, be clear in your concern and what you want. Work to present the facts as best you can and state clearly your desire to call them and all others who impact healthcare into more just relationship with you and your physician. While insurance companies are not the WHOLE problem, they contribute significantly to the problem and that is what you are asking them to be accountable for and to change.



Major Insurance Company List with Contact Information

SUGGESTED POINTS TO MAKE IN YOUR LETTERS: (see more at Negotiations)

1. YOU EXPECT THEM TO CREATE MORE ETHICAL HEALTH PARTNERSHIPS WITH PATIENTS AND PHYSICIANS.

2. YOUR HEALTH INSURANCE PREMIUMS CANNOT CONTINUE TO INCREASE AND WHY.

3. PHYSICIAN CONTRACTS, REIMBURSEMENT AND NEGOTIATION METHODS MUST BE FAIR.

WHY FAIRNESS TO PHYSICIANS MATTERS TO YOU AS A PATIENT:

A) It matters to you because it is what is ethical and just. You do not want to be a silent party to injustice.
B) You want your medical decisions and care to be in the hands of you and your physician, not a 3rd party financial company.
C) When insurance companies do not pay physicians adequately several things can happen that impacts your care as a patient:
   1. Physicians restrict services or close practices. That affects YOUR access to quality care.
   2. Some physicians try to see more patients to make up the income so they can stay in practice. That affects the quality of your care, your satisfaction, their satisfaction AND your safety.

4. SUMMARIZE AGAIN AT THE END WHAT YOU WANT, invite or challenge them to ethical partnership with both patients and physicians and tell them you expect a response.

5. Put at the bottom of your letter CC: and list the names of people you are sending copies of your letter



Here are more details to help inspire your thinking as you write your letters:

1. YOU EXPECT THEM TO CREATE MORE ETHICAL HEALTH PARTNERSHIPS WITH PATIENTS AND PHYSICIANS.
Invite, call, challenge your company to co-create more ethical health partnerships with patients and physicians. Ethical health partnership includes fairness, justice, regard for the well-being of patients and their physicians, for quality care, for patient safety, and for strengthening the physician/patient relationship as the core of healthcare. Ethical health partnership also means that while companies need to make a profit, it is unacceptable to you to have them make profits at the expense of patients and/or physicians. Let them know that this is an issue for YOU, the patient.

When you can find a statement of mission, vision or values on the company website, relate your points to those values that they claim guide their actions. Tell them you want them to act in a way that has integrity with those values.

2. YOUR HEALTH INSURANCE PREMIUMS CANNOT CONTINUE TO INCREASE:
Health insurance premiums have doubled and sometimes tripled over the past 5-7 years. You are tired of it. Projections show that insurance premium rates will continue to increase at a rate that far outpaces increase in worker's wages. (Milliman's Inter-company Rate Survey states that HMOs are expected to raise premiums for renewals up to 15%. Between 2002-2003 premiums increased 13.9% while the health plans payments for medical costs increased only 9.6%. Managed Healthcare Executive reports that the rates have gone up 11.2% as of October, 2004. They put that into perspective by noting that the rate of inflation in the same time period has been only 2.3% and the rise in worker's earnings were only 2.2%.)
Increasing rates continually add to the number of uninsured as more and more people cannot afford the increasing premiums. (Is it possible that YOU will not be able to afford it in the next few years?) Express your concern. Encourage them to address the root problems instead of easy surface issues.

3. PHYSICIAN CONTRACTS, REIMBURSEMENT AND NEGOTIATION METHODS MUST BE FAIR:
There are 2 basic parts to contract issues.
A. As part of a 'take it or leave it' approach that insurance and network management companies assume, physicians are stuck with clauses in their contracts that impact medical decision-making, referral to specialists, limiting treatment options and more. Decisions affecting your diagnosis, treatment, and care belong with the physician/patient relationship, not with insurance or network management companies.

B. Insurance companies have been decreasing physician payments (up to 30% over the past 8-10 years) WHILE YOUR premiums are sharply increasing. It is unjust that a physician would be paid today, less than what Medicare would have paid him or her for the same procedure in 1995. That is what happens every time a surgeon does gallbladder surgery, or removes hemmorhoids. Cheating physicians out of their fees is unjust. . . . especially when not only the cost of living is increasing, but so is practice expense. Malpractice rates are skyrocketing. Many insurance companies say that they set fees based on work involved, practice expense, and liability risk. Yet, while risk has gone up and practice expense has gone up, reimbursement has gone down. Physicians are being squeezed out of practice. Paying fair fees is not the driving force behind rising health care costs. As physician rates have gone down, costs continue to climb steadily. Insurance companies are not addressing the core driving forces of higher costs. Instead they are targeting the 'easy' approaches to saving money which is unjust to patients and physicians and ultimately creates more problems.

Let them know you expect your insurance company, which you are paying, to pay just fees to physicians and to create fairer negotiation policies with physicians. A physician in solo practice or even small groups have essentially NO negotiating power with insurance or network management companies. (See quotes from one network management report below) Let the company know you want them to create fairer methods of negotiation.

WHY FAIRNESS TO PHYSICIANS MATTERS TO YOU AS A PATIENT:
A) It matters to you because it is what is ethical and just. You do not want to be a silent party to injustice.

B) You want your medical decisions and care to be in the hands of you and your physician, not a 3rd party financial company.

C) When insurance companies do not pay physicians adequately several things can happen that impacts your care as a patient:
1. Physicians restrict services or close practices. That affects YOUR access to quality care.

More and more physicians are reducing services that have excessively reduced fees and considerable liability risk. Some physicians are retiring early, not because they want to, but because they have to. Others are simply closing their practices or moving to other states that make practice more financially feasible. (This is especially true if you are in one of the 'crisis' states like Florida, Pennsylvania and more.) It is NOT ONLY a malpractice rate problem, although that is certainly a huge problem. It is the combination of malpractice and REDUCED REIMBURSEMENT that makes it harder and harder for physicians to keep their practices going.

2. Some physicians try to see more patients to make up the income so they can stay in practice. That affects the quality of your care, your satisfaction, their satisfaction AND your safety.
If physicians are having to rush through patients, there is more chance of error. The financial pressure from insurance companies creates a climate where MORE error is likely to happen. In addition, squeezing in clients and rushing through damages the physician/patient relationship which impacts quality of care and satisfaction. In an effort to make quick decisions and be efficient, rushed doctors are less likely to allow you the important role of asking questions and fully discussing your condition or your care. That is not good for either of you!

4. SUMMARIZE AGAIN AT THE END WHAT YOU WANT and tell them you expect a response and want to know how they plan to address your concerns. You can issue them an ethical challenge like the one here, or suggest other actions (see a list of some here.) Write us with ideas and suggestions that you have.

5. Put at the bottom of your letter CC: and list the names of people you are sending copies of your letter. (Include all the top level management, if you have names and any boards of the company. Some others you might want to consider are: your state's insurance commissioner or comptroller, your governor, state legislators. You might also want to send a copy to your physician . . . it might make his or her day! At the very least it lets our physician's know that we are taking an active role in OUR efforts to co-create an ethical health partnership with THEM as well.)


TYPICAL INSURANCE COMPANY RESPONSES: (Don't let them brush you off!)
1. They will tell you that health costs are increasing and they have to contain costs. Sometimes companies will try to lead you to believe that if they are fair to your physician, it will cost you more as a patient. Trying to make it an either/or situation is inaccurate AND it is a way to weaken patient/doctor partnership and power. Respond by reminding them that health insurance company profits are higher than they have been in 10 years, that executive pay is excessive when they are acting in ways that create harm to patients and physicians, and that it is NOT physician pay that raises fees (especially since as physician reimbursement has gone down, premiums have gone up!) (What causes higher costs are things like technology, hospital costs, and increasing chronic illnesses in patients (many of which are due to unhealthy lifestyles.) Challenge them to think and act creatively to address the REAL health cost problems instead of trying to take an easy bandaid approach which is cutting physician fees or raising patient premiums. By doing that, they shoot themselves in the foot since they will have less providers and less patient customers!

2. They will tell you repeatedly that your physician has agreed to those fees and/or that they have negotiated those fees with your physician. Ask them about their negotiation process. (Most times they simply present their plan to physicians, tell them how many plan members they have, and the physician either takes it or leaves it. If the plan is large, physicians can't afford to NOT be a part of it, so they are over a barrel. Let the insurance company know that YOU know that physicians cannot join together as group to negotiate anything with an insurance company. They are bound by anti-trust laws (and insurance companies are exempt and that you and others will be seeking to change that imbalance of power.) That means an individual physician or a small group has NO leverage with a large company. There is no real negotiation. (This is also true when physicians try to get insurance companies to change contractual issues that sometimes compromise your care as a patient. In all these, physicians have no leverage or power in the negotiation.) That is part of the injustice.

Here is an example of what one of the largest network management companies brags about in their annual report:

"Our unsurpassed growth equals power. As more customers choose PHCS as their health care cost management partner, we leverage the strength of their 15 million members to achieve the best savings in the industry. . . . we enjoy a very powerful position in the industry. . . ."
When talking about their fixed fee approach:
"Providers, on the other hand, request straight discounts or discount off of billed charges. . . .we are witnessing a growing trend as an increasing number of providers are threatening to terminate from our network if we do not accept new financial arrangements ­­ arrangements that are not in the interest of our customers Our position is to refuse to negotiate under the threat of termination." (Note: this company's 'customers' are insurance companies and employers).

"Milliman USA projected a composite unit cost increase of 7.4% for inpatient, outpatient, physician and ancillary services in 2003. While other health care organizations may accept a 7.4% increase as an unavoidable component of today's health care environment, we recognized that . . . we needed to set more aggressive goals. We challenged our contracting staff to keep cost increases far lower than the projected trend ­­ and they succeeded. . . . (and) . . . enabled us to keep average composite unit costs to just 2.6%."
(Since this included hospital inpatient costs, and hospitals have more negotiating power than individual physicians, I am curious how much physicians were squeezed in this 'negotiation' process.

Tap the Power 2003 report.
I have not yet found a financial report for this company that shows their profit margin. If anyone finds it, let us know!

Don't let companies brush you off. Use your voice and your power as patients and physicians in partnership.


Related Resources and Actions:
Also see Reimbursement Section on This Site for more info

Ethical Health Partnership Challenge to Insurance

Lawsuits Against Insurance Companies for Unethical Behavior Toward Physicians

Insurance Company Addresses or Links

Insurance Commission links

What Physicians Can Do (coming soon)


As always, I welcome your constructive comments and suggestions about the material on this website and how we can all be most effective in co-creating the kind of healthcare system we all want. E-mail me at ideas@ethicalhealthpartnerships.org

© Dawn Lipthrott, Ethical Health Partnerships, 2005    www.ethicalhealthpartnerships.org
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May be copied and distributed as long as this identifying information is retained on copies.)