This column was originally published in AMA eVoice on Nov. 29, 2007. Dr. Davis is president of the American Medical Association.
Good news emerged out of New York earlier this week when state lawmakers promised to pass a law that would force health insurers that unfairly rank physicians (known as "profiling" or "economic credentialing") to put patient care first instead of using cost as the sole measure. Legislative leaders, along with state Attorney General Andrew Cuomo, said they will base the law on a series of agreements that Cuomo recently reached with several of New York's largest health insurers that will set new standards for conducting physician profiling programs—a terrific turn of events for the state's patients and physicians.
The AMA's Private Sector Advocacy (AMA-PSA) unit, with great assistance from the Medical Society of the State of New York (MSSNY), helped set the stage for these agreements a few months ago by meeting with the Office of the New York State Attorney General to share concerns about profiling programs used by CIGNA, Aetna, and United Healthcare, as well as tiered and narrow networks that are based primarily on economic factors. The attorney general's office has continued to solicit the AMA's and MSSNY's input in negotiating these agreements with the health insurers, and has been very responsive to the AMA's concerns about physician profiling programs. Credit also goes to AMA President-elect Nancy Nielsen, MD, PhD, who has been the leader for the AMA on this issue.
When driven by a corporate profit agenda, physician profiling programs give patients misleading information and disrupt care by causing confusion and apprehension. That's why efforts among health insurers to profile physicians must be aligned on the primary goal of promoting high-quality patient care.
I commend Attorney General Cuomo and his staff for securing these crucial protections for patients and physicians, and I hope lawmakers and regulators in other states will soon realize they have an important public responsibility to establish proper oversight of health insurers to guarantee that physicians are profiled fairly and accurately.
Efforts like this in the private sector are characteristic of the AMA-PSA unit, a valuable resource for physicians that—along with specific principles and guidelines that the AMA House of Delegates approved for pay-for-performance (P4P) programs—has helped the AMA emerge as a leader in pointing out how P4P and other physician profiling programs should be constructed.
Profiling and P4P only scratch the surface of what the AMA-PSA unit offers. The AMA's staff of private sector advocacy experts also provides information on a wide range of practice issues and serves as an advocate for doctors in challenging the inequitable business practices often used by health plans. Working side by side with national medical specialty societies, as well as state and county medical associations, the AMA-PSA unit advocates for everything from eliminating payment hassles and unfair claims denials to reforming antitrust laws and halting further health insurer consolidation.
That last example is particularly important because of the situation in Nevada, where United HealthGroup's proposed buyout of Sierra Health Services would result in one company having a stranglehold on the state's health insurance market. The AMA strongly opposes the proposed buyout and, along with the Nevada State Medical Association, is urging the U.S. Department of Justice and the State of Nevada Office of the Attorney General to file a lawsuit that would block it.
Given the long-term impact of consolidation on the marketplace, the AMA-PSA unit annually produces "Competition in Health Insurance: A Comprehensive Study of U.S. Markets," the definitive resource on health insurer consolidation. The 2007 edition provides a look at health insurance market concentration, including market concentration and health insurer market share information for 313 metropolitan areas in 44 states. The data in this report provide powerful rationale for our efforts to challenge health insurer mergers and push for antitrust relief for physicians.
The AMA-PSA unit also offers substantial guidance to help physicians and their practice staffs understand each aspect of the claims revenue cycle—from the establishment of a fee schedule and policies on patient financial responsibility to the initial appointment process and through the final appeal. Physicians can access a multitude of educational tools and resources on these and other aspects of medicine's business side, such as managed care contracting, silent preferred provider organizations, and Medicare Advantage.
In addition, the AMA-PSA unit compiles relevant information regarding the Multi-District Litigation Settlements and the Blue Cross and Blue Shield Settlement to help physicians who are experiencing payment problems with health plans.
With the AMA-PSA unit's resources at their fingertips, physicians are empowered to help themselves with any number of managed care issues they encounter. I encourage you to tap into the private sector resources the AMA offers, and if you're having trouble with a health insurer, please e-mail the AMA-PSA unit with your questions or concerns.
The lighter side
Hanukkah begins next week and Christmas is fast approaching, too. Radio stations are already playing holiday songs.
A year ago, the American Society of Composers, Authors and Publishers announced its top 25 most performed holiday songs for the past five years, based on a radio airplay monitoring service. Leading the list was "The Christmas Song (Chestnuts Roasting on an Open Fire)," written by Mel Tormé and Robert Wells, and performed by Nat "King" Cole.
Many other great songs are on the list. But missing is my favorite Christmas song—"I Want a Hippopotamus for Christmas." The song and lyrics are available on the Web, background on this 1953 hit appears in Wikipedia, and it's played against a backdrop of hippo graphics on YouTube.
What does this have to do with health? Well, the Hippopotamus song also appears on the Web site of the National Institute of Environmental Health Sciences (NIEHS). On its Web page for kids, NIEHS explains that "music is an important part of our 'environment' [and] … music can measurably reduce stress and pain levels [and] … sing along activities are very educational."
The Centers for Disease Control and Prevention (CDC) has gotten into the act as well. The CDC has produced a holiday health song, sung to the tune of "The Twelve Days of Christmas." This delightful rendition addresses important messages such as washing hands, being smoke-free, fastening seat belts, and getting exams and screenings. At a few speaking engagements in the coming weeks, I plan to play the song; full audience participation will be required.
Please send comments, questions, and replies to amaprez@ama-assn.org.
Content provided by: Ronald M. Davis, MD