One of the ways modern healthcare is shaped by insurance

 

People need to be aware of the ways that insurance companies shape how doctors treat people, as it affects their personal care. There are multiple terms and groups that people have never heard of that become important to medical practices and getting paid. Some of the ways that insurance makes demands are common sense, which should make people wonder why doctors are doing certain things. At the same time, the demands raise administrative costs for doctors, while shaping how they can be paid.

Quick Disclaimer

This article is for education purposes, not as a complaint against any of the people mentioned. It is so that people will know about an important part of their lives. Much of the way that this information was gathered for understanding was by getting to talk with someone who has been an insurance quality professional for almost two decades. Some of it can be disturbing to some, while other parts are just a way for people to gain knowledge. 

NCQA and HEDIS

One of the groups that people need to know about is the National Committee for Quality Assurance (NCQA), which is a not for profit that is responsible for the ratings that insurance companies get. They do this through meetings, classes, and yearly audits. One of these audits is called HEDIS, which stands for Healthcare Effectiveness Data and Information Set. The audits are run by companies that have permission from NCQA to do so.

Most insurance companies use their results, especially those managing Medicare and Medicaid as part of their services. The commercial side can use this for star ratings, which helps them market their quality. While all of this seems to be organized, at the end of the day the companies have to decide on software to use that have different outputs and different ways to gather the data. Some companies have a large share of the information gathering process that do not have the confidence of the people needing the data but use networking to schmooze with executives to get contracts.

Information Measures

For a few years, the NCQA has used the same measures as a way to see how people are getting care in certain areas. They then will change the measures they pay attention to, which means that the insurance companies have to change what they focus on, which then leads to a change in how they want medical practices to communicate with them and get paid. This leads to insurance companies paying more for certain tests and treatments. Quality departments will need certain information at other times, which will lead them to have the medical practices to do things for unpaid codes.

There are coders, both full time and contract, which are used by medical practices, so this part does not have to be an administrative issue. The problem is when busy practices have to change what they focus on to make sure they can pay their employees. This is made worse when it is Medicaid, which has a horrible record for paying medical practices. The practices also have their records used as a way for insurance to question how they treat patients. One way this is good is by questioning why there are antibiotics handed out for issues that would not be helped by this medication. Thankfully, some of the people who are part of the monitoring process are doctors and nurses who have left practicing medicine.

Population Care

One of the disturbing trends, especially in areas with higher population density, is to treat populations and not individuals. With the way that insurance is limiting treatments, higher costs, and the need for more employees, doctors have to use assembly line thinking that kills people. This also means that they could miss certain medical issues that would have needed them to pay more attention to their patients. This is made worse when the medical records are passed through companies that are untrustworthy or compromised. Look at what happened recently with Change Healthcare to understand this nightmare.

This article in no way is meant to cause people to dislike audits, but how they are used is political and shapes medical care. Medical practices are closely watched for what they do to make sure the companies get the best score they can. While some of it is necessary, it also makes healthcare more expensive. The next time you go to your doctor and the office wants to do something they have never done, it could be because of what was just talked about here.