In my opinion, the biggest issue for healthcare practices today is their lack of control over their destiny. In a sense, they never had any – and any independence and mastery over their future was only illusory. However, it has become painfully clear to me after almost 34 years in healthcare that this is the biggest challenge facing independent groups and independent physician associations today.
Their payments, if part of managed care or accountable care, are often subject to the whims and fancies of the HMOs or CMS. Rules can change arbitrarily or retroactively, and data can change, be hidden, or contested as needed. Payments come months later, sometimes as late as 18-24 months.
The small practices need more resources to challenge these numbers – nor the ability to review them independently. As a result, they rely heavily on health plans and CMS while providing service and producing data, with the data utilized by the payers or regulatory authorities.
PBMs are a complete joke. They pay one amount to the manufacturer and charge another to the insurance company. Part D expenses have layers within layers of commission and hidden charges. Drug prices are increased by 13-15% annually, and no one can lift a finger to address this issue.
Recently, a health plan refused to share any bonuses and conveniently refuted the data it had shared over the last 12 months with us consistently over its portal. The CEO of one of the largest health insurers had no problem completely changing numbers and reducing benchmarks by 30%, and when challenged, he agreed to restore the reduction 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 her health plan. All this is done covertly and illegally while flouting all professional relationships and etiquette.
She broke her contract with an oncology network and denied having signed the agreement and when confronted, conveniently apologized for her mistake while insisting on the legitimacy of her move.
This behavior is reprehensible, and witnessing providers on the receiving end of this collusive and collaborative systemic bias is distressing. What is the solution?
There is only one in my mind. Providers must get their act together, whether referring to compliance, operations, technology, or financial planning. Providers must manage their own data, harness new technologies like AI and RPA to improve efficiencies, network to create more equitable contracts for their services, and build effective compliance and regulatory platforms to increase their earnings and improve their safety.
Providers have to control their destiny, and they can only do this when they are not just producers of data but also consumers, managers, controllers, and appraisers. Then, and only then, will they have the financial and legal ability to take on the emerging forces arraigned against them and can bring better value for their “low premium services.”