[justsometwerp]

so let's clarify a few things. All the things you described that suck (e.g. preauth, drug renewal, etc) are made to suck, on purpose, by ... drumroll ... you insurance company which, believe it or not is usually a for profit entity (USA USA USA) and therefore is incentivized to take your money and not pay any out in premium. Paying for your care to them is a loss, and what they do is try to minimize loss ratio. (remember obamacare loss-ratio cap checks from eon ago?). So how does, a for profit company that you paid premiums to ration your healthcare to minimize loss ratio: by creating the most arcane, convoluted, confusing and inefficient process standing between you and your care provider. This is not a bug with front desk, this is a feature of your for-profit insurance. The flip side of the coin are of course all the STEMI docs, who show up there just to perform a dangerous and provably useless medical procedure day in and day out, because profit:) It's like digging out an outhouse, it's ** all the way down.

[adolph]

Part of the problem is informational. Payors, which may include those backed by nonprofit (like BCBS) and government (CMS), are tasked with reducing un-necessary and duplicative services. This is a critical duty in bending the high cost of healthcare.

Payors identify specific procedures or treatments which represent things they want more information about before they commit to paying for it. It is difficult work on the healthcare provider side to understand what requires pre-auth and provide the payor's decisional information. There is a HL7 group that is working on the problem, the DaVinci Project:

Interoperability challenges have limited many stakeholders in the healthcare community from achieving better care at lower cost. The dual challenges of data standardization and easy information access are compromising the ability of both payers and providers to create efficient care delivery solutions and effective care management models. The goal of the Da Vinci project is to help payers and providers to positively impact clinical, quality, cost and care management outcomes.

http://www.hl7.org/about/davinci/index.cfm?ref=common

[drknownuffin]

Yes, let's clarify a few things. For starters, I'm a physician, and have formerly worked in health insurance at the management level. I assume your comment was aimed at someone at a different level of familiarity with the topic. I'd be happy to re-evaluate my understanding of your comment if you'd care to clarify with the newfound knowledge that I'll understand a more nuanced argument, if you care to provide one.

Responding to what you have written, however:

1. I provided a direct explanatory mechanism for how physician reimbursement caps lead to low-quality auxiliary services - by pointing out that investing in an activity or service that provides no marginal revenue is a strictly money-losing proposition. You assert, without mechanism or evidence, that this is strictly due to "for profit insurance." You need to clarify how the insurer, and their profit motive, creates this result - as the mechanism I put forward simply requires that the physician is has a fixed fee schedule and is at capacity volume. I won't go so far as to assert you should take my word on it, but you could do worse than listening to a doctor say "this is exactly what's going on in my and my friends' practices."

2. The majority of healthcare dollars in the United States flow through Medicare and Medicaid. Given that these services reimburse quite a bit lower in dollars/service than for-profit insurers, they actually make up a larger volume of total services rendered. I can't argue with a statement as vague as "usually a for-profit entity," but I can state more precisely that it "will be a non-profit entity for more than 50% of services and more than 50% of reimbursed dollars."

3. Minimizing loss ratio has nothing to do with what I said at all. If you can put forward a mechanism that translates my front desk expenses into reduced MLR for the payor, I'm listening with open ears. Look at this thought experiment: let's say my insurer's MLR stays flat, and I can accept a 100$/yr subscription fee from all of my patients to improve front-desk service, with the caveat that I'm taking a profit off the top. Would the insurer care? No? Is there anything the insurer's payment processes would do to affect this? No? Then the issue is my profit motive, not the insurer.

4. The convoluted payment processes are there to aid the insurer in sorting through their giant piles of paperwork (you didn't think that administering a health insurance network was low in bureaucracy, did you?) and, more cynically, to create pitholes for us to step into so patient care is denied reimbursement. You're going to have actually, again, provide a mechanism by which that translates into "Doctor doesn't improve services offered." Because I can tell you that if the bureaucratic hurdle that is insurance billing doesn't step me from billing in the current environment, then it's not going to stop me from billing for higher amounts if I could get them.

[albroland]

From the insurance side: I found the throwaway's reference of MLR very confusing and seems to be misinformed about the ACA market and MLR caps in particular.

Exchange plans are just about the most price sensitive insurance product I can think of; in ACA markets typically the lowest premium plan will capture the overwhelming majority of the signups. Insurance co's are highly incentivized to optimize their MLR to provide the maximum amount of care up to the rebate threshold, while driving costs down as much as possible to ensure you can offer the lowest premium plan on the exchange and be the take-all winner.

Also, so much of prior auth, step therapy, etc are dictated by federal or state regulations and not necessarily what the insurer would like or prefer to do.

There are plenty of pain points in our insurance industry but to carte blanche blame "for profit" companies seems really lazy.