The Challenge for Independent Health Care Practices

The biggest issue facing healthcare systems today, in my opinion, is the lack of control over their destiny. In a sense, perhaps, they never had any freedom, and mastery over their future was merely an illusion. However, after nearly 34 years in health care, it has become painfully clear to me that this is the biggest challenge facing independent groups and independent physician associations today.

Payments, if they are part of managed care or accountable care, are often subject to the whims and fancies of the HMO or CMS. Rules can be changed arbitrarily, or retroactively, and data can be changed or hidden, or conflicted as needed. Payments arrive months later, sometimes 18-24 months late. Smaller practices do not have the means to challenge these numbers, nor the ability to review them on their own. Thus, they are dependent on health plans and CMS, being true providers of service and true producers of data, which are consumed by payers or regulatory authorities.

PBM is a complete joke. They pay one amount to the manufacturer and charge the other amount to the insurance company. Part D costs have layers of commissions and hidden fees. The price of medicines increases by 13-15% every year and no one can point a finger to solve this issue. Most recently, a health plan refused to share any bonuses and simply dismissed the data it consistently shared with us on its portal over the past 12 months. The CEO of one of the largest health insurers had no problem completely changing the numbers and reducing the benchmark by 30% and when challenged agreed to reinstate the cut 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 his health plan. All this is done in a surreptitious and illegal manner, flouting professional relations and etiquette. He broke his contract with an oncology network and refused to sign the agreement and when confronted, he readily apologized for his mistake while asserting the legality of his move.

 

It stinks and it is extremely painful to see providers on the receiving end of this collusion and collaborative systemic bias against them. What is the solution?

There's only one in my mind. Providers must get their act together, whether it's compliance, operations, technology, or financial planning. Providers have to manage their data, using new technologies like AI and RPA to improve efficiency. Network together to create more equitable contracts for your services, and build robust compliance and regulatory platforms to improve your earnings and security.

Providers must control their own destiny, and this can only be done if they are no longer creators of data but also consumers and managers, controllers, and evaluators. Then, and only then, will they have the financial and legal capacity to face emerging forces and bring more value to their 'low premium services'?