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Providers, insurers need to end the acrimony and collaborate
Bridging the gap is the only way for patients to receive affordable, quality care
All health care providers have partnerships with many different organizations — community groups, academic institutions and research entities, to name a few. These alliances typically change and evolve over time. Some work better than others, of course, but all sides benefit when they work well. Most importantly in our industry, the ultimate winners are patients.
As all providers know, one of our principal partners is often our biggest nemesis: the insurance companies that pay our bills. The relationships with payers vary from one company to another, and there are many examples of productive relationships. Overall, however, they are too often marked by tension, combativeness, misaligned incentives and diminishing trust.
Understandably, both sides are under pressure — providers from patients and regulators, and insurance companies from businesses and government to better manage costs and improve quality. But we can and must do better. The time has come to end the acrimony and rethink how we can collaborate.
Most of the complaints from the provider side stem from the administrative burdens of getting prior authorizations for patient treatment, contract complexities and payment denials, all of which can drive up health care costs and, in too many circumstances, compromise the provision of clinical care.
It doesn’t have to be that way It's time to find a better way to settle our differences or government will step in and do it for us.
To create an efficient and sustainable health care delivery system, providers and insurers need to reimagine how to better align incentives and goals to improve the long-term health of patients and communities.The adversarial status quo needs to be replaced with more cooperative, positive partnerships. This new model should be guided by the following:
Recognize that the treating physician should be the one making clinical decisions. That premise is too often challenged by insurers that question after the fact whether the care delivered was medically necessary, even though they had no interaction with the patient or family and no liability if something goes wrong. The treating physicians are the ones who know the details of their patients’ conditions and are best equipped to decide what care is appropriate and the safest place to deliver it.
Simplify the payment process
Hospitals and physicians often face long delays in getting paid for services already provided. While it varies by company, insurers deny reimbursement requests for between 25% and 50% of care provided. The process of resolving payment disputes often takes up to a year or more, driving up legal fees and monopolizing staff time. In the overwhelming majority of cases, the decisions of treating physicians are upheld, but in the meantime, providers lose revenue, which is especially detrimental for public, rural and financially distressed hospitals that are already struggling to keep their doors open. It’s an unnecessary tug of war that drives up the overall cost of care. To correct the problem, there should be a partnership model whereby providers get paid for services upfront, but insurers are reimbursed if they successfully challenge a provider’s treatment decision.
Northwell CEO Michael Dowling talks leadership, healthcare unity, and tackling social threats to health.
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Redesign the prior authorization process
This is a major area of public dissatisfaction in which physicians must get pre-approval from insurers on a course of treatment before moving forward. The process often delays necessary treatment, causing distress and potential harm to patients. In today’s world of automation, technological wizardry and artificial intelligence, there is no reason why this process — if it is not eliminated — cannot be improved.
Make joint investments in community health
Achieving and maintaining good health depends on much more than what happens inside a hospital or doctor's office. It’s largely influenced by personal lifestyle choices, behaviors and the level of access to quality care in our communities. Joint investments by providers and insurers to address the social determinants of health, which have created enormous disparities in life expectancy, would be a major step forward in improving access and overall health. There would be no greater foundation for a true partnership.
Although it should be self-evident, leaders at provider and payer organizations must constantly remind themselves that the health care system exists to serve the public, not their own business interests. Now is the time to address the long-standing issues that have contributed to such acrimonious relationships.
For real change to happen, it needs to start with those of us at the top. CEOs of insurance companies, health systems, hospitals and the trade organizations that represent us must work together to establish a level of trust that has been missing for far too long. We must ensure that those responsible for managing our relationships abide by the ground rules already spelled out in our contracts.
We are on the cusp of historic breakthroughs in medicine and research. Given their critical roles in the health care ecosystem, providers and insurers must be aligned in their commitment to strengthen the delivery system, preserve the financial integrity of the payment system, and oppose any movement toward a federal- or state-initiated single-payer system that would have negative consequences for providers, insurers and the public.
Michael Dowling is president and CEO of Northwell Health.
This op-ed originally appeared in Modern Healthcare (paywalled article).
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