Whom are the certifying organizations really serving?
March 21, 2015
At DocSpot, our mission is to connect people with the right health care by helping them navigate publicly available information. We believe the first step of that mission is to help connect people with an appropriate medical provider, and we look forward to helping people navigate other aspects of their care as the opportunities arise. We are just at the start of that mission, so we hope you will come back often to see how things are developing.
An underlying philosophy of our work is that right care means different things to different people. We also recognize that doctors are multidimensional people. So, instead of trying to determine which doctors are "better" than others, we offer a variety of filter options that individuals can apply to more quickly discover providers that fit their needs.
March 21, 2015
An American doctor summarized some drama surrounding the American Board of Internal Medicine (ABIM) over at BMJ Blogs. Essentially, doctors have been chafing at ABIM's growing requirements for certification (board certification can be a requirement for employment at certain institutions, such as hospitals). Part of the backlash has been about the financial cost, and in one debate, Dr. Charles Cutler highlights a culture of luxury within the leadership of ABIM (as well as detachment from the practicing physician).
It'll be interesting to see how this story plays out, but for our purposes, there is a question of what obligation ABIM -- as a non-profit whose mission is to "enhance the quality of health care by certifying internists and subspecialists" -- owes to the general public. One interesting statistic is that somewhere between 95% and 98% of physicians eventually pass the certification exam. The public is only told who is or is not certified; we are not told, for example, how many times a physician had to take an exam in order to pass, nor are we told how well a physician tested. The theory is that any doctor that becomes certified is qualified to treat patients, and therefore patients do not need any further information -- that theory is not very reassuring for patients who have experienced a seemingly wide range of outcomes when visiting different doctors. Given that ABIM goes through all of this trouble to test doctors, it would be helpful for them to parlay the results into some more meaningful signals for patients. A previous chairman, for example, written about releasing actual percentile scores so that they can be combined with other factors to help patients make decisions; alas, transparency within health care moves slowly.
Another question is whether certifying organizations should view the certification data as mostly a revenue channel, or as a public service. Sure, consumers can look up individual doctors on a related website, but that can be rather tedious (versus, for example, doing a specialty search within a geographic area). It's also nice to be able to compare doctors on other metrics, whether that be the incursion of disciplinary actions, patient ratings, or even something as simple as distance from a specific location. When we've inquired about licensing this data, we were surprised by how expensive the data is (cost-prohibitive given where we are as a company). It seems to us that ABIM (and the related ABMS) would actually further their mission of enhancing the quality of health care by freely and publicly releasing board certification lists so that patients can more easily take advantage of decision support tools. But, as Dr. Cutler pointed out in his video debate, financial compensation to ABIM's leadership is pretty high, and that money has to come from somewhere.
March 14, 2015
Last week, I noted how Medicare sets prices for procedures. Fortunately, the U.S. Department of Health & Human Services (HHS) announced earlier this year that they will be overhauling how healthcare providers will be paid. The goal is to move away from fee-for-service, where providers are paid by volume (the more they do, the more they are paid, regardless of whether the patient needed the procedures) and instead move towards "value-based payments" where the patients' outcomes are considered.
This move makes a lot of sense, although hopefully the metrics will be refined as the transition gets underway. HHS announced a goal of tying 90% of hospital payments to quality and value metrics by the end of 2018, which might seem aggressive -- however, hospitals have seen movement towards this model for several years now. It'll be interesting to see how the payment model and quality metrics change for doctors over time.
March 08, 2015
Medicare sets the prices that it will pay providers for specific procedures. These prices consider locality (i.e. procedures performed in certain zip codes will be paid more than in other zip codes, even though the same procedures were performed) and some other factors (e.g. whether the provider is a teaching hospital). For the most part, Medicare pays different providers in the same locality the same price for the same procedure. On one hand, this makes some sense -- why should the same procedure be paid different amounts just because they are performed at different locations? On the other hand, in what other industry are prices set the way that Medicare sets them in health care? Can you imagine being able to go up to any hotel and demanding the same price as the hotel down the street? Even in the airline industry (where customers have largely the same experience), airfares can vary significantly. In large part, Medicare can get away with setting prices because it is the nation's largest payer.
So, what happens when Medicare sets a price for a specific procedure too low? Duke Medicine reported an interesting finding: the frequency of that particular procedure dropped, but the frequency of a more expensive procedure went up. From the article, it's unclear if Medicare's price reduction caused the frequency of the other procedure to rise, but the time periods overlap very nicely. Additionally, the other procedure lacks evidence to demonstrate that it is superior. Therefore, it seems likely that when reimbursement for the original procedure was cut, providers looked around for alternatives and found one that they like more.
Whenever a market has its price set for external reasons, distortions occur. Medicare could additionally regulate a price decrease for the other procedure, but chances are that providers will find another alternative, or not enough people will get the right procedure. In a more classically functioning market, consumers would be exposed to a greater part of the financial cost, they would also know the price of the procedure ahead of time, and they could choose which provider to go to. We might be headed a little closer towards that model (with patients being exposed to higher deductibles and co-insurance) and we might experience plenty of short-term pain (in the absence of meaningful pricing information) before the market becomes healthier.
February 28, 2015
Back in May of last year, I was excited to learn that three major insurers were banding together to make health care prices available to consumers. There seemed like there was so much potential. This past week, The Health Care Cost Institute announced that their portal launched as Guroo.com. It turns out to be a rather modest step -- currently, it only gives average pricing by location, and only for seventy or so conditions . Granted, this is only the launch, and the press release hints at much more to come. However, this data seems available via some other sites, and this release falls far short of what the portal could do with the data that they have (e.g. price comparison among providers).
At this point, the rationale for these insurers to release this information remains unclear. Do they actually want to change the provider industry by helping patients make more informed healthcare purchasing decisions (which in turn should lower their costs)? If so, releasing the information at the individual provider level makes a lot of sense. It would make even more sense to release this data so that other tools can also harness it to benefit the patient community. Do they want to build and control their own popular consumer-facing portal (as someone from Robert Wood Johnson Foundation suggested they have the potential to do)? Do they want something that they can point to in the realm of healthcare transparency for the sake of appearance? We'll see how the site develops, and how they respond to competitive websites.
February 22, 2015
Whether a physician is considered in-network or out-of-network by a patient's insurance plan can have large financial implications. Unfortunately, ascertaining that status can be difficult. Kaiser Health News ran an interesting article exploring one couple's difficulties in this area. In this particular case, a doctor was part of two different medical groups and could bill under each one. The doctor billed under one medical group that was not in-network, resulting in out-of-network charges for the couple, despite the insurance company's own website assurance that the doctor was in-network. It was a bizarre case of the doctor's staff having more influence on the final charges than the actual patient.
Insurance network coverage can be tricky and in our own investigation, we have found plenty of incorrect insurance information. While not a perfect solution, one step that would help immensely would be for insurance companies to release network information in a industry-specified format that could be understood by computers. Tools could be built on top of those data feeds to help physicians catch errors and to help patients make better decisions.