Patients need a more direct path to a doctor’s treatments and cures

Patients need a more direct path to a doctor’s treatments and cures

Doctors and experienced patients know that health insurance coverage is a promise rather than actual care and that delivery on that promise is variable Many times large deductibles and co-pays block patients from receiving needed treatments.

For me, a frustrating experience occurs when one of my patients needs a non-steroidal salve to soothe an ache or a quality of life drug for their erectile dysfunction or a potentially life saving CT Scan or MRI that their insurance won’t approve. 

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Many times, a tortuous appeal process is unsuccessful. In fact, I have never met a physician who looks forward to dealing with health insurance. All of the doctors I know would rather accept a lesser direct payment rather than beg for reimbursement for a service they’ve already provided.

 

There is also too little price transparency. Insurance companies and middle managers negotiate prices with drug companies and other service providers, but create a smoke screen to true health-care costs.

One solution is to decrease or remove the role of the middleman — also known as Pharmacy Benefit Managers (PBMs) — and return to the days of direct care between provider and patient. 

This is exactly what General Motors is doing by contracting 24,000 non-union employees to receive direct care (known as ConnectedCare) from the Henry Ford health system (there is currently no relationship between Henry Ford health and the Ford Motor Company) in Detroit.

Henry Ford will provide prescription drugs, same and next day care without a wait, surgeries and medical care from 32,000 providers. The program is designed to save $300 to $900 per year in premiums. it will set prices but will have to meet 19 quality points of health-care delivery to receive maximum payments. Blue Cross will only play a peripheral role in terms of processing claims, but will no longer be the decision maker.

How will employees benefit? By getting rid of insurance company and pharmacy interface approvals, patients will have more direct access to treatments without delay. Medicine is entering an era of exponential innovation and precision medicine, with genetic-based treatments and single injection immunotherapy cures like CAR-T in the offing.

A six-hospital health-care system like Henry Ford is much more in a position to be flexible in terms of payment schemes for emerging technologies than is any one-size-fits all insurance. If the system works smoothly, this should mean fewer denials of personalized treatments. 

What about quality of care? Is it possible to restrict access to only one medical center and still preserve top notch care? In the Detroit area, there are two other highly ranked medical centers in Wayne State and Beaumont and just 30 minutes away in Ann Arbor is the top ranked University of Michigan.

So there will be times when a GM employee will feel restricted, unable to travel to the  University of Michigan or Beaumont, say, for a top specialist who isn’t available at Henry Ford.

On the other hand, chairman of neurosurgery and medical director of Henry Ford Cancer Institute Dr. Steve Kalkanis wrote to me in an email this week that the Henry Ford Health System has an “extensive physician network” experienced in “delivering value-based care with outcomes-driven metrics.” 

Kalkanis believes that the new arrangement will promote “better access, lower cost and greater accountability for results,” and could serve as “a template for collaborations with additional corporations from around the country.” 

Is Kalkanis right? Other employers are starting to think so. Disney, Boeing and Intel are getting into the act and a survey of 170 large employers just released by the National Business Group on Health revealed that 11 percent plan to contract directly with health-care providers next year, up from 3 percent in last year’s poll.  

The health-care industry currently has too many moving parts, with the patient and doctor having the least amount of control. The GM/Henry Ford direct care model (which will also include telemedicine services) not only cuts down on waste, it also puts the patient more in the driver’s seat.

Self-serving health insurance companies and other middlemen clog the path, cloud transparency and limit access to real health-care solutions. Patients have also wanted and deeply deserve a more direct path to a doctor’s treatments and cures. 

Marc Siegel M.D. is a professor of medicine and medical director of Doctor Radio at NYU Langone Health. He is a Fox News medical correspondent.