Work with health plans to boost patient outcomes
Good guy/bad guy scenario is never helpful
If a health plan won’t cover a treatment you think a patient should have, speak up, advises Sandra Berkowitz, RN, JD, senior vice president and managed care practice leader with Marsh Inc., a Philadelphia firm specializing in insurance and risk advisory services.
"It is the patient’s interest that physicians must advocate and document," she says. Sometimes this may mean telling a patient that you recommend a treatment that the plan has not approved, and that he or she has the option of paying for it. "Sometimes you have to disclose it and document it. The record should show that you don’t stop when the benefit isn’t covered and you feel the patient should seriously consider this option."
When Berkowitz works with health plans to develop a risk management program, she asks them to think about what things they would flag, and what situations would create risk for the plan, the member, or the physician.
One red flag that plans often identify is when a primary care provider becomes very vocal in advocating on behalf of the patient, she says.
This could be because the plan has overlooked something the physician feels doesn’t put the patient first, she adds. "It is becoming clear that the physician must advocate on behalf of a member when they believe that the plan has made a necessity determination in error. The courts have become quite a bit more sympathetic to providers who stick their neck out. A fair amount of legislation has developed that forbids plans from deselecting providers because of member advocacy."
Complaining about the health plan and creating an adversarial relationship won’t help your patients, Berkowitz point out.
But working with providers to reduce the variance in outcomes in medical treatment will, she says. She cites disease management and oncology as two areas where providers and plans have been successful in developing protocols.
Berkowitz urges physicians to get involved in development treatment protocols with the health plans, pointing out that plans usually want the doctors involved to increase overall physician buy-in. "There is a whole lot of cost associated with variability whether it’s bad outcomes or a lot of treatment going nowhere. Care management is the area that has the greatest hope that both the physician and the plan are on the same page."
Rather than ranting and raving about what the plan won’t cover, it’s more productive for providers to work with the plan to create evidence-based medical standards, particularly in the case of chronic illnesses, Berkowitz says.
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