P4P for Health Insurers? by Val Jones MD

In a recent post entitled, “The Joys Of Health Insurance Bureaucracy” I described how it took me (a physician) over three months to get one common prescription filled through my new health insurance plan. Of note, I have still been unable to enroll in the prescription refill mail order service that saves my insurer money and (ostensibly) enhances my convenience. The prescription benefits manager (PBM) has lost three of my physician’s prescriptions sent to them by fax, and as a next step have emailed me instructions to complete an online form so that they have permission to contact my physician directly (to confirm the year’s refills). Unfortunately, page one of the form requires you to fill in your drug name and match it to their database’s list before you can continue to page two. For reasons I can’t understand, my common drug is not in their database. Therefore, I am unable to comply with my insurer’s wish that I enroll in mail order prescription refills. This will further delay receipt of my medication – and probably increase my cost as I will be penalized for not opting into the “preferred” mail order refill process.

Now, all of this is infuriating enough on its own, but the larger concern that I have is this: How many patients are not “compliant” with their medication regimen because of problems/delays with their health insurer or PBM? Physicians are being held accountable for their patients’ medication compliance rates, even receiving lower compensation for patients who don’t reach certain goals. This is called “pay-for-performance” and it’s meant to incentivize physicians to be more aggressive with patient follow up so that people stay healthier. But all the follow up in the world isn’t going to get patient X to take their medicine each day if their health insurer or PBM makes it impossible for them to get it in the first place. And shouldn’t there be consequences for such excessive red tape? Who is holding the insurers and PBMs accountable for their inefficiencies that prevent patients from getting their medicines in a timely manner?

Pay-for-performance assumes that physicians are the only healthcare influencers in the patient compliance cycle. I’ve learned that we only play a part in helping people stay on the best path for their health. Other key players can derail our best intentions, and it’s high time that we look at the poor performance of health insurers and PBMs as they often block (with intentional bureaucracy) our patients from getting the medicine they need. While insurers save money by having patients struggle to get their prescriptions filled, doctors are payed less when patients don’t take their medicines.

Not a great time to be a doctor or a patient… or both.

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  4 comments for “P4P for Health Insurers? by Val Jones MD

  1. Marco
    December 1, 2012 at 8:42 am

    If the same concept of “pay for performance” were to be applied to bureaucrats including the POTUS, I am wandering what their income will look at the rate they waste our tax money.
    So far, it looked that the new system cuts costs by creating excuses (well based on statistics) not to pay providers. Adding intentional bureaucratic interference may be step #2 on the ACA manual.

  2. J. R. Johnson
    November 28, 2012 at 10:17 am

    The Affordable Care Act was designed to make health insurance companies behave better. I am no fan of big government, but what other organization has the authority to make the health insurance companies improve their product? The free market approach doesn’t work as we saw more uninsured citizens and higher premiums for less healthcare value throughout the last few decades. Healthcare is different and more important than widgets or broccoli. Unfortunately it appears that improvements in healthcare will need to be legislated.

  3. Anonymous Coward
    November 28, 2012 at 10:00 am

    I was once told that one of the best ways to get the attention of an insurance company is to sick the state insurance examiner onto them.

    The insurance examiner is not interested in individual complaints about the insurance company, but they are very concerned about its cash flow, because if an insurance carrier were to become insolvent, many people would be affected.

  4. November 27, 2012 at 3:29 pm

    Good insight, excellent piece.

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