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January 2016
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  • Has Patient-Insurer Relationship Jeopardized the Doctor-Patient Relationship?
    ISMS President
    Scott A. Cooper, MD

    It’s a serious question. We still hold the doctor-patient relationship sacred, of course; it remains the foundation of medical ethics. But if you ask physicians, every year the doctor-patient relationship becomes more difficult to establish and maintain.

    One key reason for this? Health insurance hassles.

    The health insurance market is more convoluted than ever before, but complexity does not always imply ample choices. Patients may spend hours researching their options only to find that there are relatively few affordable plans available to them, and that their preferred physicians or institutions are not in-network.

    Is it time to redefine our relationship as "patient-insurer-doctor?" Or more likely, "patient-insurer-hospital-doctor," as the practice of hyper-narrow networks aligned with certain health systems becomes more prevalent?

    Not so fast. Patients and physicians can still advocate for themselves and for their relationship. But it's not as simple as it used to be.

    As we witnessed from recent changes to coverage offered by Blue Cross and Blue Shield of Illinois (BCBSIL) through the state insurance exchange, calling your preferred doctor's office to see if they accept your insurance now involves more than a simple "yes or no" question. In this case, the PPO offered through the exchange is not the same PPO available to many patients with employer-based coverage. Blue Cross is limiting the exchange PPO network to roughly half of Illinois' hospitals. If a patient in that plan isn't paying attention, his or her physician may not be "in-network" to them if the doctor isn't on staff at one of the hospitals in the narrow network – even if that physician otherwise accepts Blue Cross.

    Patients need to be savvy enough to explore other insurance options (if available) and ask a heck of a lot of questions now during open enrollment. This means researching specific plans, not just insurance companies, and speaking with their physician's office before enrolling.

    It’s not as easy for us either. We generally find out about insurer changes after they occur, and face limited time windows to ensure our existing patients understand potential care disruptions. In some case there's no time to react, as was the case with the Land of Lincoln co-op's announcement it was dropping a health system entirely. The co-op is an exchange plan and the announcement came after open enrollment concluded for current insureds.

    It's important that we know what plans we (and other physicians to whom we often refer patients) are in. It's also critical that we be prepared to discuss these issues with our patients.

    I don't have the answers for how to fix these latest wrinkles, but I can assure you that ISMS is very seriously investigating these network issues.

    Let us hear from you on your experiences with insurance hassles. Write to me at DrCooper@isms.org. You can also seek assistance through use of our Hassle Factor Log program.

    In next month's column, I will share my experience about shopping for new insurance and having to ask many of the same questions our patients now face when evaluating plan options. 

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