Tis the season for Naughty or Nice - Health Insurers making a List & Checking it Twice

     During the holiday season we hear ”he knows if you’ve been bad or good “ and “be good for goodness sake.” The “he” might be your PPO or HMO insurance company. They monitor prescription refill rates, lab follow-ups and health screenings. The health insurance company sends friendly reports on delinquent patients to their doctors. So when your monthly prescription bottle of 30 pills, lasts you 40 days, it flags you as a non-compliant patient. “ … gonna find out who’s naughty or nice…”

     You might think, “Who cares?” Well, the doctor/ medical group might care when it shows up on the doctor’s quality rating. For example, once anti-depressants are started, they should be taken for a minimum of six months or so. Even if the doctor advised it or prescribed it, it lowers his quality of care rating when his percentage of patients finishing six-month courses of treatment is low. When you look up a doctor on your insurance website, and see how many stars he has on the quality area, this is one criteria. “… he’s making a list and checking it twice…”

     Lab follow-up is important and “quality” doctors do advise it. So if you have high blood pressure, diabetes or other health problems that has a EBM (evidence-based medicine) protocol, then be good and don’t have lapses. Every diabetic should have an A1c test every six months. If you don’t show up for the blood test and no lab billing ever goes to your insurance company, then you are being non-compliant. (With computerized records they will have direct access to tests being done and test results, without just waiting for billings.)

     What about that screening colonoscopy that your doctor has been advising you since you turned 50? So you’re 55 now and both you and your doctor have been showing up on the “naughty or nice” list (n/n list) of the insurance company. Oh, by the way, while you are waiting to schedule, just ask for the home stool test. It is not nearly as accurate in screening for colon cancer (only 5 percent versus 90 percent with colonoscopy). But it helps you and the doctor with being on that n/n list.

    

Now that you know a little bit about how insurance companies rate doctor quality, now let’s look at “efficiency” (think $$$ ).

First you need to know that no matter what the doctor charges, the managed care insurance company has a contracted rate that the doctor must accept in order to be in network.
So how do they rate a doctor for cost? Part of the answer lies in what he orders: if any X-ray, CT or MRI is ordered for an uncomplicated low back pain, then that goes on the naughty list. In treating ear infections, if amoxicillin is not the first antibiotic, then off to the n/n list. If any antibiotic is prescribed in the first four days after an office visit for bronchitis, then n/n list.

     Of course doctors use their clinical judgement and are used to non-clinicians overlooking their art of medicine. So, let’s sing, all together now: “You better watch out, You better not cry, Better not pout I’m telling you why…”  (It’s better than the alternative: “having a blue Christmas without you …”)