Tennesseans deserve a health insurance market which promotes both affordability and access. This legislative session, the Tennessee Medical Association is supporting solutions to restore that balance.
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As a physician leader, I strongly disagree with the opinion of Scott Pierce, COO of Blue Cross Blue Shield of Tennessee, regarding proposed healthcare legislation that is supported by the Tennessee Medical Association (TMA).
In his Feb. 26 op-ed, Pierce stated that healthcare premiums would increase if SB 2550 (which requires insurance companies to notify healthcare providers sooner when there is a change in reimbursement policy) and SB 2155 (which establishes a Tennessee commission of insurance review, among other regulatory changes) are passed.
But insurance premiums increase nearly every year. For most Americans without employer coverage, good quality and widely accepted private health insurance is simply not affordable. Employee health insurance costs are one of the very largest expenses any business owner pays. This is not a phenomenon driven by proposed legislation, but we do hope such legislation will help to curb healthcare costs overall.
Patient frustrations, higher costs
Honest and hard-working Tennessee families have continually faced rising premiums, higher deductibles and insurance networks that shrink every year, forcing them often to find new doctors. It makes little difference if they are covered by a for-profit or not-for-profit insurance company. The games we are forced to play are pretty much the same.
How do I know this? Patients complain to me about these issues every day I practice medicine. Every year, well meaning physicians and sick patients are forced anew to navigate prior authorization requests, poorly explained claim denials, altered provider network panels, revised drug coverage rules and reimbursement changes. These disrupt patient care and medical practices’ long-term viability.
Physicians waste a large portion of time, manpower and payroll — not on patient care, but on navigating a fragmented healthcare landscape. Patients are not spared these time-consuming tasks. My own wife, who has multiple chronic conditions, deals with it all the time, so I know firsthand how awful it is for patients and their families. Both patients and their physicians deserve transparency on these topics.
The cost of operating a practice in Tennessee continues to rise. Rural hospitals face closure. Reimbursement for services continues to be cut year after year. And longstanding, respected independent medical practices face the untenable choice of merger, selling out or closure.
How new legislation can improve Tennessee healthcare
The TMA is supporting legislation to address the following issues:
Payment transparency and predictability: Traditionally, insurance pays the medical practice for services rendered. The practice then pays its staff (both medical and administrative) wages and benefits, insurance, rent, utilities, etc. Arbitrary and unannounced payment reduction by an insurance company for services rendered to a complicated patient is a violation of trust. These cuts inevitably force practices towards more appointments per unit of time and potentially lower quality of service. This is completely unfair and dangerous to patients.
Timely access to necessary medical care. There are certain types of procedures and medications which nearly always get approved after a prior approval request or initial denial. But approval should be sustained. It should not face reevaluation six months later — particularly if the chosen treatment is effective, or if six months is too early to determine effectiveness. The amount of manpower insurance companies expend challenging proper medical care adds to healthcare costs, and thereby premiums, because insurance companies have to pay their people too. Your rising healthcare premium and increased deductible pays that additional cost for them.
Fair and sustainable provider payment structures. Vertically integrated medical systems are a phenomenon wherein large private companies, like insurance firms, own a pharmacy company, the pharmacy benefit management structure and sometimes a group of medical practices. It has been recently proven that these structures raise costs because they act as a monopoly.
Healthcare workers within such a structure have little independent decision-making capacity and are badly overworked, while the doctor-patient relationship becomes a shell of itself. We must protect fair payment models for community-based medical practices, to help ensure they are not forced into vertically integrated systems. This is better for all communities, regardless of size.
Tennesseans deserve a health insurance market which promotes both affordability and access. This legislative session, the Tennessee Medical Association is supporting solutions to restore that balance.
John D. McCarley, MD, is the president of the Tennessee Medical Association.
Clinton Mora is a reporter for Trending Insurance News. He has previously worked for the Forbes. As a contributor to Trending Insurance News, Clinton covers emerging a wide range of property and casualty insurance related stories.