Somebody Blinked

As noted earlier, BCBS started a small revolution with their plan to eliminate payment for out of network surgeons in the 2009 FEHB program. (That’s the most popular plan for federal workers.) Lots of finger pointing between BCBS and OPM over who’s idea this was, but no one was willing to back down, despite the approaching end of the open season for employees to choose. This change came to light fairly late in the process as some began to read the fine print in their contracts. Those marching in the streets wanted to rescind the proposal or extend the open season to give employees more time to evaluate choices. Those in power wanted neither but eventually relented and extended the season one month. What’s the skinny here? BCBS and OPM maintained they were just trying to protect patients from large bills from out of network surgeons. They did offer a cap on individual expenses of $7,500 per surgeon, per operation. Rather like a high deductible health plan with no matching savings account. Employees saw this as a decrease in benefits (with an increase in premiums), since BCBS would pay nothing in 2009, whereas they paid something in 2008. There is a little smoke and mirrors here. If they were sincere about capping patient expenses, they could have done that but left their out of network reimbursement the same as 2008. Sorry fellas. On the other hand, if you’re dedicated to lowering expenses for healthcare, you gotta luv em. The basic idea is to force patients to use network surgeons, where BCBS can negotiate (read “control”) fees. Those surgeons who choose not to join the network will find themselves without BCBS patients, and that’s a major segment of the local population. No numbers yet, so the outcome is a guess. Mine is that anyone remotely contemplating surgery will switch to another plan. Inertia will preserve many BCBS patients. No major effect. This year. Next year, other plans will adopt the same strategy. Next next year, this policy will be extended to all providers, not just surgeons. This is just the first shot across the bow in a quiet war on physician fees.Why? If you balance all the cost factors in U.S. healthcare against systems in other industrialized countries, one major difference surfaces: we pay our doctors--particularly surgeons--more than anyone. There are other drivers of healthcare expenses, and technology is the number one cost factor overall, but physician fees are right up there. So what’s the poor doc to do? How can he keep gas in the Ferari if no one will pay his fees anymore? Well, not quite no one. Many are dropping all insurance and opting for boutique medicine. I used to pay $1,000 a year to keep my Lexus running, so why balk at $800 for my primary care provider visit? This may work in Washington, but what about Peoria? (My favorite small, midwest town.) Another solution is to become more efficient, so you can see more patients in a day. Other industries have done this. There are people who make their living by improving processes, and there are even some healthcare examples. Look on the ASQ web site for books about healthcare and “Lean.”For surgeons, demand efficiency in your hospital. Do your cases always start on time? Always? Does the circulating nurse have to leave the room to get something that was missing? Is there a time in the OR when the patient is there but nothing is really happening to the patient? How long does it take? Does anyone do it faster? Try benchmarking the speedier spots.Expect more pressure on physician fees, starting with specialists but eventually extending across the board. There will also be intense scrutiny on technology--those weird and wonderful new toys and techniques that cost more to do the same job, or maybe just do a job that not everyone thinks needs to be done. How much is it worth, and who is going to pay?