Reform Health Care Now: Insurance reimbursements make no sense

When I opened my own medical practice more than four years ago, I decided to do my own billing so I could learn how medical billing worked. Instead of hiring an office manager, I handled all disputes with the dozen or so health insurance companies whose plans I accepted as well as Medicare and the state-run Medicaid program.

It was a rude awakening. I was not new to medicine -- I had spent five years in another private practice and another six years working for Kaiser Permanente -- yet I was shocked to learn that getting reimbursed by a health insurance company is often a game of coding and standing up for what's right. And if I wanted to get reimbursed for my work, I needed to learn how the system works -- or I might not stay in business for long.

I soon realized that that insurance company reimbursements are often arbitrary and nonsensical. For example, the majority of insurers won't pay you for both a routine checkup and treatment for another problem at the same time. If a patient comes in for her annual Pap test and she suspects she has a cyst, the insurance company expects the doctor to either evaluate the problem and not get paid or ask the patient to come back for a separate visit if the doctor expects to get reimbursed for providing both services. Obviously, insurers are hoping that physicians take care of all of a patient's problems in one visit so they don't have to pay for all of doctors' work.

The same is true if a doctor has to perform two surgical procedures on a patient. If a doctor is doing a hysteroscopy to remove a polyp but the same patient also wants an ablation to reduce heavy menstrual bleeding, many of the insurance companies bundle the two codes together and only pay the doctor for one procedure. Even if two procedures are done in different areas of the patient's body, some insurers reduce the payment of the second procedure by as much as 50 percent. Insurers know that physicians would never be so unethical as to make a patient undergo two separate surgeries, but it appears that they have no problem not paying fairly for extra work performed.

Meanwhile, professional medical societies have issued coding guidelines spelling out the correct way physicians should code each distinct problem. Insurers, however repeatedly disregard these recommendations. Instead, they make up their own rules -- and every insurer has its own set -- forcing doctors to keep all these rules in mind when dealing with patients.

So the way doctors get paid doesn't make sense and it obviously affects my income, but how does this adversely impact your health care? One of the ways insurers have cut costs is by paying doctors less and less over the years, and it appears that many doctors have responded by doing more. They may ask patients to return for frequent visits or performing extra tests to receive added compensation. In many cases, the way care is being delivered becomes inconvenient for patients, ultimately drives up costs even more, and may not improve outcomes. If we truly want to control costs, we have to change from a reactive to a preventive standpoint and physicians' pay needs to be based on how well they take care of patients.

Perhaps the most problematic practice of all is how preventive care is disincentivized by our current system. Doctors get paid very little for time in spent with patients compared to the amount they can make ordering tests and performing procedures. If I spend an hour speaking with a patient I might get paid as little as $80, but if I do an endometrial biopsy, which takes under five minutes, I get paid $150. Sure, doctors who do procedures frequently have had to go through additional training, but a friend who's a pediatrician says that she can spend five minutes removing a wart and get paid more than she does for any other office visit regardless of how long it takes. The same is true of internists and family practice doctors.

As a result there's a shortage of primary care doctors. In fact, that brings up one of the glitches in the health care reform plans on the table: Right now many uninsured people rely on the ER for primary care, but if we are able to provide coverage to the nearly 50 million Americans without insurance, we will need more primary care doctors to see them, and we must compensate them fairly. One proposed solution, paying medical specialists less, hasn't gone over well, and most likely won't get the medical community's support.

And we learned back in 1993, in order for health care reform to pass, you have to find a solution all the players can buy into. Until this problem is solved, physicians are going to continue to practice medicine in a way that compensates them adequately as opposed to what's best for patients.

This is the fifth article in a 10-part series, 10 Reasons to Reform Health Care Now:

Part 1: Syrocketing costs are choking American businesses

Part 2: 87 million uninsured, and growing

Part 3: The economy is making the crisis worse

Part 4: The current system emphasizes quantity over quality

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