Physician-Insurance Company Relationships are Changing

By Wyman Bowers, SCMA Associate General Counsel

When an insurance company approaches you indicating they have an innovative approach to managing your patients and asks for a meeting, most probably you have hesitations and reservations, naturally.  The relationship between the payor, in this instance the insurance company, and the payee, the physician, is one in which the objectives and goals are not in complete alignment.  The reasons for this are numerous, but what I will submit to you is that this relationship is not unique.  In virtually every context in which business transacts, and let us not forget that health care is a business, one party seeks to provide goods or services for compensation, which the other party pays.  In the vast majority of instances, the one who provides the goods or services thinks that they are worth more than the party who is paying for them; while on the other hand, the paying party thinks the price is on the upper end of the value of the goods or services.  

This is not intended to be an economics lesson, but rather one that highlights the opportunities that exist within health care as we know, and live, it today.  As it seems the only constant is change, one can either take the perspective that a defensive posture is a sound strategy, or that an offensive one is a more correct approach.  In all likelihood, a combination of the two will prove most advantageous.  Therefore, while the defensive component would dictate holding one’s ground, the offensive perspective would necessitate exploring new alignments, new partners, and new ventures.

The Patient Centered Medical Home (PCMH) is one such innovation that is worthy of your consideration.  The basic concept is not novel in its theory, but in its application.  PCMH envisions team based health care delivery model led by a physician that provides comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes.  Though the focus is upon primary care at the present, this model is expected to expand to specialty practices.

A distinguishing characteristic of the medical home model of today is that payors, both commercial and Medicaid, is that the payors are willing to pay the physician to adopt this model.  I realize this is not a totally novel approach, but it is one that is gaining traction around the country and in South Carolina.  

The point, though, is to reflect upon the strategy you are deploying in your practice: is it only defensive or do you have offensive weapons in your arsenal as well.  Moreover, relationships between physicians and insurance companies, hospitals, and others do not look the same as they did even five years ago. Thinking about these relationships is changing.  The challenge to physicians is to lead that change.