Physician Patient

Archive for the ‘Message from the President’ Category

Up to their old games: Minnesota insurance companies are denying mental health claims

Wednesday, November 6th, 2019

Up to their old games?
Undeniably, denying claims is the managed care business model. “Captain may I” managed care prior authorizations and claims denials are the dominant health care rationing strategies of Minnesota insurance companies and third party administrators (TPA) contracted by self-funded corporations.
United Healthcare (which originated in Minnesota) is the reigning champion of these practices.
Claims denying is used extensively for managing mental health claims. That’s why mental health advocates pushed for mental health parity laws. However, the deal-breaking caveat for implementing state and federal mental health parity laws to expand coverage is this: Medical necessity is determined (defined and decided) by the managed care company itself, not by the patient’s health care “provider” (physician, psychologist, social worker, etc.), or an independent arbitrator, or most importantly by the consumer (patient and family). And the denials can occur before, during, or after treatment is provided.
I left employment as a mental health medical director at a large Minnesota PPO years ago because I couldn’t work for an enterprise that advertised and competed with other managed care companies touting its effectiveness in denying patients’ mental health claims.
How best to fight third party mental health claims denials? Stop contracting with third parties. Most Minnesota physicians are now employees and their organizations do the dirty work. Independent doctors can be paid by their patients. And patients themselves can get payments from their insurance companies.
Complaints and public pressure require tireless and Sisyphean efforts on the part of both doctors and patients. The managed care stone always rolls back on one; its corporate economic power and mass exponentially growing. When patients have skin in the game they will complain. And patients’ complaints matter most when they are reinforced by other patients and community mental health advocacy organization such as NAMI-Minnesota. Or if the rolling stone is an asteroid law suit involving lots of public money and taxpayers. [See the Westin case and MN AG Mike Hatch’s suit against BCBSM in 2001 http://news.minnesota.publicradio.org/features/200106/19_stawickie_bluecross/]
Uncollected accounts receivable in a private practice? The bigger they become the more the doctor is pushed into giving up her independent practice. That’s part of the UHC playbook as well.

Healthcare 2020 Reform: Competing for patient-directed dollars. Direct Primary Care

Sunday, August 4th, 2019


Comment on the “Goodman Plan” (above) from Dr. E. John English:
      Dr. Goodman’s ideas describe “Primacare Direct” http://primacaredirect.com/ that’s right here in the Twin Cities. Some important tweaks however.
  •  An independent primary care physician should NEVER accept payment directly from either Medicare or Medicaid for this prepaid plan. Only accept money directly from the patient. The whole reason the direct primary care thing works is that it is ‘direct care’ – – -between  you and the patient. Period. Let the government/ third party figure out how to do this through the patient – – -not on behalf of the patient.
  • Some other critical points:
       The direct care clinic determines what is covered and what is not covered – – – not some third party
       The direct care clinic determines the monthly fee charged – – – not some third party. 
                Thus fees/benefits may vary between clinics – but that’s the point – clinics will begin to compete for patients
                             Cover too little or charge too much, no patients – – -thus the ‘market’ will dictate how to proceed
       Based on above, the patient chooses a specific doctor in an accepting direct care clinic.
                                                – – – absolutely no assignment should be accepted by some third party. This is major. 
                                                – – – naming a specific doctor creates a direct line on responsibility
      The contract is month to month.
      The patient enrolls by making the first visit and signing up with a specific doctor (not a clinic)
                                                – – –  No paperwork is sent anywhere
      Payments come in monthly in the name of that specific doctor – by automatic credit card deduction
      There is NO billing and NO coding and NO reporting to any third party – – – – only directly to the patient
                                                – – – Thus the doctor’s note can be brief and to the point
      There is NO oversight of  the primary care physician’s care by any third party.
                                               – – – The patient alone will decide if they like/want the type of care they are receiving
                               In other words, “Quality care” is defined by the patient satisfaction, not some third party
      Unsatisfied patients make their wishes known – – – – with their feet, by either:
                                A. Choosing and visiting another specific doctor within the same clinic
                                               – – –  payments begin coming to that specific doctor
                                B. Choosing another specific doctor in another accepting direct care clinic
         Now for all specialty care coverage – – -80 / 20 indemnity plan with stop loss. (E. John English, MD )
In the televised Democratic candidate debates this past month we learn that all Medicare for All proposals mean the end of employer-purchased third party health care insurance which now covers more than 150 million Americans. See: https://www.npr.org/sections/health-shots/2019/04/11/711902886/as-sanders-calls-for-medicare-for-all-a-twist-on-that-plan-gains-traction
Current polls indicate that health care is the number one policy concern for Americans. Democrats were successful in the 2018 US congressional election (taking control of the House) by amplifying voter concerns about high health care cost and access to quality care while claiming that Republican policy proposals would not cover patients with pre-existing medical conditions. All of the Democratic candidates (including Sen. Amy Klobuchar https://www.youtube.com/watch?v=JeDPmFd_IYU ) want more government control and management of US health care.
What will US employers (large and small) support politically? How could or would a Medicare or Medicaid buy-in (such as Minnesota Governor Walz’s ONECare https://www.mprnews.org/story/2019/02/21/how-gov-walz-health-care-buy-in-plan-works) affect market competition for consumer-controlled dollars? What do patients and families want?

Marie Fishpaw at the Heritage Foundation and  I propose five health reform ideas. They are short, easy to understand and hugely impactful on consumer-directed reform. In each area, the Trump administration has already gone about as far as it can administratively. Congress needs to complete the tasks. Here are five goals of health care reform which can empower patients. For patients:

1. Personal, “portable” health insurance that travels with them from job to job and in and out of the labor market.


2. Round-the-clock communication with their personal physicians by phone, email, and Skype.


3. Telemedicine, so they can even “visit” the doctor from home — avoiding traffic, long waits, and unneeded emergency-room visits.


4. Centers of excellence that specialize in chronic health conditions (including preexisting conditions) which actively compete for patients.


5. Accounts owned and controlled by patients who are willing to manage their own care, including most forms of chronic care and even routine surgery.


Government should not mandate these changes. If employees and their employers like the arrangements they now have, they should be able to keep and modify them. But government needs to get out of the way, cut red tape and conflicting requirements, and quit interfering with the opportunity for people to have better options.

John C. Goodman

President

Goodman Institute for Public Policy Research

6335 W. Northwest Hwy., #2111

Dallas, TX  75225

202-679-9622

johngoodman@goodmaninstitute.org