Doctors warn that U.S. health care  will implode if government health plan cuts physician pay by 27% in the next 33 days. Many will no longer accept government health care patients, exacerbating  the shortage of access to care in this country for those reliant upon government health care.

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          In today’s issue of the Brownsville Herald there appears an announcement by a local physician of his decision to no longer accept Humana Insurance patients.

The problem with this, as we see it, is the fundamental nature of the patient / physician relationship. Patients should be able to choose any physician of choice. Physicians should retain the same right in choosing and building their client base without third party interference.

A patient/physician relationship is based upon a contract. The physician agrees to provide a service and the patient agrees to pay for that service. A third party, such as an insurance policy should be irrelevant to the transaction. The insurance policy will pay what it will pay, nothing more and nothing less, irregardless of the patient/physician contract.

However, the traditional patient/physician relationship has changed with the advent of “Managed Care.” Patients and employers who sponsor group medical insurance have essentially given up their “contractural rights”  by allowing  third party intermediaries to represent them and be bound by them. Physicians, historically poor businessmen, have done the same.

Purchasing health insurance through carriers that require participation in their proprietary PPO networks such as Humana, Cigna, Blue Cross, United HealthCare and others effectively handcuffs the patient and physician to a very large degree.  The patient/physician contractual relationship is relegated to “second class citizenship” status by secretive PPO contracts that effectively rule the relationship and has “veto” power over both of the intended beneficiaries.

The good news is some employers who sponsor group health insurance and fed-up physicians are, after 25 years of failed Managed Care strategies (arranged and supported by third party intermediaries) are taking back control.

Self-funded employee welfare plans is the only vehicle available to employers who want to take back control of the patient / physician relationship. The fully-insured group medical market is not a viable option.

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A South Texas employer group has made the decison to drop their PPO network and pay physicians  U&C. Facilities will be paid using Medicare as a benchmark.

The rationale?: Why pay PPO access fees, (disclosed and undisclosed)  when instead  you can just pay providers what they get anyway? Seems to make sense.

Editor’s Note: There are two species of medical providers – doctors and hospitals. Doctors  want to be paid fairly and promptly. Most hate PPO networks, insurance companies and other intermediaries who “manage” health care. They sign PPO contracts only because they want to be advertised as “preferred.” Doctors would like nothing better than to be left alone to practice medicine. Hospitals, are different. They consider PPO networks as their outside salesmen and partners. They dictate pricing while PPO intermediaries demand ” discounts” to justify their fees. Inflated and arbitrary pricing accomplishes both objectives.

The largest hospital system in Georgia, Emory Healthcare, entered into a clinical affiliation with CVS Caremark’s MinuteClinic, opening up the door to convenient care for consumers, the latter announced yesterday.

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With ObamaCare looming, and the expected death and planned extermination of private health insurance carriers in this country  by 2014, insurance companies are positioning for continued profits by supplementing government health care programs such as Medicare and Medicaid through niche products. Transitioning strategies include acquisition of urgent care centers (Humana- Concentra), Medicare supplement business, entry into foreign markets (Aetna – China) or a  total exit from health insurance to other lines.

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Bill:  Thought I’d share this white paper produced by GFOA and Colonial Life.  I’ve not read it yet, but the summary I read outlines a few of the things you’ve been talking about for several years now, wellness programs, onsite clinics, and developing a consumer mentality in the employees.    GFOA_2011WhitePaper_ContainingHealthCareCosts

Editor’s Note: This was sent to us by a county official in Texas. See Page 6, item #2. This is where this market is going. See also Health Care Strategies for Texas Political Subdivisions

Ford D. Albritton, M.D. Dr. Albritton is Board Certified in Otolaryngology, Head and Neck Surgery and is a Fellow of both the American Academy of Otolaryngology, Head and Neck Surgery and the American College of Surgeons. Please Note: *Accepted insurance plans are subject to change. However, we do accept most insurance programs.To ensure that we accept yours, please call 214.345.1400   Accountable Health Plans Of America Inc PPO (Interplan Health Group) Admar PPO/Merged With Proamerica Through BCE Aetna HMO/PPO Aetna Medicare Advantage Affiliated PPO Affiliated PPO AHI – Healthlink (Formerly Affiliated Healthcare) Amcare HMO ( Formerly Amerihealth HMO) BCE Emergis Beech Street PPO/Cappcare PPO Blue Cross Blue Shield HMO Blue Cross Blue Shield PPO/POS Cappcare PPO/Beech Street Carrollton-Farmers Branch ISD PPO CCN Managed Care Inc PPO Centra PPO Choice Care (Formerly Humana/Employers Health) Choice Care Medicare Advantage PPO Network Cigna Care Network (Specialty Care Network) Cigna PPO Cigna HMO City Of Carrollton PPO CCN Managed Care Inc PPO CPL Federal Reserve Bank Of Dallas First Care HMO First Health PPO (Formerly Affordable/Healthcare Compare) First Health Ti PPO Freescale (Formerly Motorola) Galaxy Health Network PPO Golden Rule Ins Co (Purchased By United Health Eff 9/1/04) Greatwest Healthcare HMO (Formerly One Health) Greatwest Healthcare One Plan (Formerly One Health) Greatwest Healthcare POS (Formerly One Health) Greatwest Healthcare PPO (Formerly One Health) Healthcare Partners Of East Texas Healthtexas Provider Network Healthsmart/NTHN EPO/PPO Healthsmart/NTHN GEPO Healthsmart/NTHN POS (HPET) Healthcare Partners Of East Texas Humana (Choice Care) IMS PPO Independent Medical Systems PPO (Formerly Integrated Medical Systems) Intereplan Heath Group-Accountable-Interplan Lewisville ISD PPO Lumenos (Baylor Employees) Managed Healthcare Inc PPO Medical Control PPO/PPOnext PPO Multiplan PPO Multiplan PPO National Healthcare Alliance PPO North Texas Health Network (Name Changed To Healthsmart) NPPN Pacificare HMO Pacificare PPO (PHCS) Private Health Care System Open Access (PHCS) Private Health Care System PPO/Open Access Plano ISD PPO PPOnext PPO/Medical Control PPO PPO Smartnet (Subset Of Choicecare/Humana PPN- Premeir Provider Network Proamerica Managed Care Inc PPO (BCE Emergis) Pronet PPO Randalls Food Markets PPO Regional Healthcare Alliance PPO Santa Fe Employees Hospital PPO Secure Horizons Direct Southwest Preferred Network (Alliance Health) PPO Texas Health Choice HMO (Kaiser Permanente) Texas Instruments (Ti) PPO Texas Medical Resource PPO Texas Municipal League PPO (TML) Texas True Choice Texas True Choice Star PPO TRS-Care (Texas Public School Retired Employees) TRS-Active Care PPO (Texas Public School Active Employees) Unicare Classic PPO/Preferred Unicare Performance United Health Care Choice Plus & Select Plus POS United Health Care Choice & Select HMO United Health Care Options PPO USA Managed Care Organization USC Health Services PPO Texas Institute For Surgery UHC Genesis DPS Renewal Beech Street Workers’ Compensation New Contract Amendment Interplan Health Group Workers’ Compensation (Formerly Identified As Accountable) New Contract Amendment Medical Savings Plans (Through Galaxy) New Contract Amendement

Holy Smoke! How does this guy know what he is going to get paid? Smith with Blue Cross pays him $10 while Jones with Cigna pays him $11 for the same service. Then in comes Garcia with TTC who pays him $13.22 for the same service that Jones recieved. Yabolonski comes in with UHC and pays $9.53 for the same service Garcia received……………….

Then in comes Don Pedro with cash…………….and pays $3.50

Editor’s Note: If we  remove  the addiction (health care intermediaries such as the ones listed above) we can reduce health care costs by more than 40%. A San Antonio employer did  – Bill Miller Forbes.

From The Desk Of Molly Mulebriar:

 Bill, let me see if I understand this post. Ford has contracted with every PPO in the world, “discounting” his fees for service in return for patient steerage to his facility. That is the premise behind PPO’s – doctor charges less so that his name can appear in a PPO directory. So, since he has signed up with every PPO out there, practically every patient he sees he will have to discount his fees which means he will almost never get to charge his full normal fees. Seems to me to be a hell of an expensive advertising campaign, having your name in all those PPO directories. An unscrupulous doctor would inflate his normal fees, then agree to a discount down to his original normal fee giving the illusion of savings.

Payments based on PPO discounts and negotiations/repricing based on provider charges are becoming increasingly ineffective cost containment solutions due to escalating healthcare provider charges. Recognizing this, many large insurers are already utilizing Medicare/DRG Based Repricing for reimbursement of some of their clients’ claims.

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