The fight against paint-by-number medicine

Many doctors tell a similar story. A patient is responding well to a particular drug or treatment, and it’s inexpensive. Then the payer stops coverage for it, forcing the doctor to try new options, which don’t work as well. 

The patient becomes stressed as one payer-approved drug after another doesn’t work, and costs rise as doctor and emergency department visits increase. Maybe it ends with the patient in the hospital. The patient isn’t as healthy, the doctor has invested more time and effort, and the payer’s costs are higher than if they had kept paying for the original treatment. 

The patient, the doctor, and the payer all lose. Yet doctors say this scenario is not uncommon.

“I understand why payers are doing what they are doing, but I had a diabetic that had her insulin switched four or five times in six years,” says Richard Bryce, DO, a primary care physician in Detroit. “It’s probably cheaper, but it’s not making her life any easier and certainly not making her healthier.”

Similarly, Peter Bidey, DO, a primary care physician in Philadelphia, had a patient in need of a urological procedure because of a recurring infection. The patient kept getting discharged from the hospital, because the payer wanted the procedure done on an outpatient basis, but this led to four more trips to the hospital and three admissions before it was finally approved.

“It’s very hard on the patient and such a horrible experience,” says Bidey. “Why don’t they just do the procedure?”

With value-based contracts becoming more common, some doctors worry that situations like these will create one-size-fits-all medicine, where individual patients and  treatments customized for their particular needs are shoved aside in favor of data-driven treatment plans. But there are steps doctors can take to make sure their voice is heard and that patient care doesn’t become generic.

Physician concerns about value-based care

Value-based care focuses on paying doctors for outcomes rather than volume. Doctors are paid more when patients get healthier, as measured, for example, through data such as A1C levels for diabetic patients. But Bryce and other physicians worry that the data-driven approach can be taken too far.

“The idea of value-based care is great,” he says. “At the same time, it’s important to understand every patient we have is different. Understanding how we are doing and reimbursing us on that is not all bad, but you can’t do it all that way. Just because someone’s A1C levels aren’t dropping doesn’t mean I’m not doing everything I can.”

Bidey’s concern is that the more data-driven care becomes, the more it will influence what a physician is willing to try. If coverage for a test has been regularly denied in the past, he worries doctors may stop ordering it, even when they believe it is justified. And for requests that are inconsistently approved, it could mean a futile 45 minutes on the phone trying to get a prior authorization when the doctor could be seeing more patients.

With physicians assuming some financial risk in value-based contracts-if the outcomes aren’t positive, doctors either receive reduced pay or no pay-they should determine how that money is spent, as long as they are following best practices and evidence-based medicine, says Pamela Ballou-Nelson, RN, Ph.D., principal consultant with the Medical Group Management Association. This should include not being limited by prior authorizations, and freedom to consider individual patient needs. 

Nelson says that value-based care, if implemented properly, should put doctors in a better position to care for patients. But it will require payers to change their thinking and not require doctors to get approval for treatment they deem necessary.

“If we move into a value-based world, payers have to let go of some of these silly protocols,” she says. “It should free up physicians to be decision-makers again on what the best course of care is.” 

Next: How payers decide what to approve

How payers decide what to approve

While every insurance company differs slightly in how it decides what treatments and drugs it will pay for, there are some general best practices that payers follow, according to America’s Health Insurance Plans (AHIP), the industry group for insurers.

“Payers use evidence-based approaches, including a systematic review of drugs and surgery devices,” says Cathryn Donaldson, director of communications for AHIP. Each plan has its own formulary that it negotiates based on the local market, but the most weight is given to drugs with clinical trials and FDA approvals.

Donaldson points out that health plans employ clinical experts, including physicians and nurses, who stay up to date on new treatments, devices, or clinical findings, and review company policies on treatment options in light of new evidence. “It’s all based on safety and affordability,” she adds.

Plans also are shaped by federal and state laws, and in the case of employer-sponsored plans, by what the employer chooses to cover. “Sometimes, if two different treatments are comparable and effective, the plan will pick the lower cost if all other outcomes are equal,” says Kate Berry, senior vice president of clinical affairs for AHIP. 

The challenge for payers-or even for physician groups determining their own guidelines for something like an accountable care organization-is that evidence-based medicine changes over time, so treatments need to change as the evidence evolves. 

“Some treatments we used to do for people that were evidence-based at the time actually harmed people,” says Maria Chandler, MD, MBA, a pediatrician in Irvine, Calif., and a member of the Medical Economics Editorial Advisory Board. “Stroke treatments that were common practice years ago are appalling now-who is to say that in 20 years, the way we are doing it now won’t be appalling?”

She says that when most doctors were in independent practice, there was no real regulating body and insurance companies didn’t mandate much, with the result that patients were being treated using varying standards.

“We’re seeing now that wasn’t so great,” she adds. “Having someone look at the bottom line, evidence, and outcomes is a good thing, but it’s out of control. Evidence-based is not the end of the discussion. It’s good in many cases, but not a blanket that fixes everything, so let’s use some common sense.”

Jack Ende, MD, MACP, president of American College of Physicians, says that guidelines are important, but should be just the starting point of the decision-making process. “Guidelines don’t tell you what to do for that particular patient,” says Ende, who practices at Penn Center for Primary Care in Philadelphia. “They give you evidence-based information on what typically works. But to translate that to the particular patient in front of you who has multiple comorbidities, that’s where the art of practicing medicine comes into play.”

He points out that guidelines provide ideal targets for conditions like high blood pressure, diabetes, and osteoporosis, but that each patient is unique and treatments have to be flexible to meet specific needs.

Doctors must be heard

AHIP has discussed with the American Medical Association ways to streamline utilization protocols in value-based care since doctors usually assume more risk. “In some cases, the plan may delegate authorizations to the provider group that’s taking on the risk,” says Berry. “What a value-based contract might typically do is focus on the importance of reducing variation of practice. This reiterates the need for sharing information and dialogue among all stakeholders.”

Value-based care will only be successful for everyone if doctors have a key role in identifying the most effective treatments and establishing the clinical protocols, says Jeff Micklos, executive director of the Health Care Transformation Task Force, an industry consortium of patients, payers, providers, and purchasers looking to transform healthcare toward more value-based care.

“Looking for cost-effective care is just one component,” Micklos says. “It’s important to share information on quality outcomes. We need to establish clinical protocols more uniformly across the system and evaluate them using data.”

Value-based care does not mean care rationing or a one-size-fits-all approach when doctors are involved in the decision-making process, says Micklos. It means doctors from all specialties will work together to achieve the best results for patients and have the data to prove positive outcomes and earn reimbursements based on superior performance.

Ende says that if a doctor has a track record of success, then payers should acknowledge that the physician is in the best position to decide what is and isn’t necessary for treatment. “When a clinician makes a decision that a patient needs a certain test or MRI, that decision should not be scrutinized to the point where hours are spent on the phone for a prior authorization,” he says. 

(AHIP, in conjunction with the AMA, MGMA, and other industry groups, announced recently that it is collaborating to simplify and speed up the prior authorization process.)

Value-based care models under which physicians assume risk have merit, because payers and doctors share some of the same goals and rewards, says Ende, but the patient also needs to be considered. “The full-risk model raises the specter of the doctor not doing something that’s needed to save money, so we have to be certain we aren’t sacrificing what’s in the best interest of the patient.”

Next: Fighting for care and proper reimbursement

Fighting for care and proper reimbursement 

As value-based care becomes more prevalent, physicians may find themselves trying to understand new guidelines so as to get approval for the care their patients need. But experts say that the strategies that worked to get payer approval under fee-for-service still apply. 

“When something that requires a prior authorization is denied, about nine times out of 10, the provider didn’t include all the required information,” says Berry of AHIP. “Almost always, when the information is provided, the request is approved.”

She adds that payers recognize that not all patients are the same, and that sometimes the evidence for the treatment options is imperfect. When a special situation arises, she says it’s important that doctors talk with the medical staff at the insurance company about the options.

If a physician has solid data that show healthy outcomes and rare prior authorization denials, he or she can consider negotiating that as part of their contract with payers, says Ballou-Nelson. “Have them give that to you as an added extra in your contract that you don’t have to do a prior authorization for ‘x,’ ‘y,’ and ‘z’ condition, because you can prove what you do has good outcomes.”

She also advises talking to EHR vendors about what clinical decision-making tools are available in their system and how the software can be customized to match the care protocols that payers require. These can remind a physician what options they need to try before a prior authorization will be approved, so that when one is requested, it has a better chance of approval.

Bryce says while he attempts to anticipate what an insurance company will approve, he does his best to keep the patient informed to minimize their frustration. “I try to give them a heads-up that their insurance might switch their medication so they have an idea that could be coming,” says Bryce. “A lot of times, it might be between a good choice or a slightly better choice of options offered by the insurer.” 

When that happens, he explains to the patient the benefits of each so they understand why the insurer is making the change and what it means to their care, but why the change is being made isn’t always known. He hopes that value-based care will eventually improve transparency in the decision-making process.

“There are good things about value-based care and definite challenges,” he says. “I think there is a model out there that can be good, but we need to make sure we have the right people designing it and hope that it works out well for the patient. I think the thing that works best for me is understanding why you are doing what you do. It always comes back to helping the patient.”