Physician Profiling, on the other hand, is OK

A year ago in this space, we analyzed the announcement from UnitedHealth Group (the second largest managed care insurer in the U.S.) that they would soon be dropping pre-authorization requirements.  Pre-authorization is the procedure by which agents of the insurance company - most of whom have at least a high school education - have to formally approve a doctor's request for a medical service before the patient was allowed to receive that service.  While we were glad to see this odious procedure being terminated, we were less than sanguine about its implications.  Among other things, we pointed out that UnitedHealth Group's announcement included the statement that physician profiling would be beefed up.

Now, a court case in Ohio nicely illustrates the advantages of physician profiling, and shows why progressive managed care concerns are more and more willing to drop pre-authorization.

Marwan Adjan, MD is suing SummaCare Health Plan in Akron, Ohio for dropping him from their physician panel after he refused to sign its "improvement plan."

Dr. Adjan had been receiving regular economic profiles from SummaCare, describing how much money the insurer was spending on patients cared for by the good doctor.  The insurer was displeased that Dr. Adjan's patients were costing them significantly more than their financial target, based on actuarial calculations, allowed. They presented him with an "improvement plan," a contract in which he would guarantee to reduce the health care utilization of his patients.  Dr. Adjan refused, holding that he was just practicing good medicine, and that his patients being particularly elderly and sick, simply required more medical services.  SummaCare, taking offense that Dr. Adjan refused to improve himself, summarily dropped him from their physician panel.  (We have fully described the typical procedure used for "physician improvement" elsewhere on this site.)

Dr. Adjan has the local reputation of being a very good doctor.  He is "a Marcus Welby," according to the chair of the managed care committee of the Summit County Medical Society.  And SummaCare itself was unable to attack the quality of care delivered by Dr. Adjan.  SummaCare had given him a 100% quality rating just a few weeks prior to his termination.

DrRich comments:

If there's anything good about this story, it's that managed care organizations are finally dropping the pretense of being concerned only about quality.  They are, of course, concerned about quality - but only secondarily.  Their main goal - the charge we have given them as a society - is to cut costs.  They would love to keep good-quality doctors like Dr. Adjan their physician panels, but they aren't going to do that if they spend too much money.

What if Dr. Adjan's patients, angered by the treatment their beloved doctor received, chose to leave SummaCare in protest?  Wouldn't SummaCare care about that? 

Well, if Dr. Adjan is right, and his patients tend to be old and chronically ill, then actually SummaCare would win twice.  Besides, health plans long ago learned that when a doctor leaves a health plan for any reason, patients overwhelmingly stay with the plan, not with their doctors.

Perhaps health plans, in displaying more openly their primary goal of spending less money, are taking their cue from the U.S. Supreme Court, which formally and publicly recognized last year that HMOs are supposed to ration health care.  That's what Congress wanted them to do when they wrote the laws (so, the Supremes said, suing HMOs for doing what they're supposed to do won't fly).

The bottom line is that perhaps cases like Dr. Adjan's will advance the public's recognition of the fact that rationing is occurring, and will continue to occur.  This recognition is the first necessary step before we can figure out how to do it fairly. 

Until then, we'll continue to ration covertly, and the chips will fall where they may.

January, 2001

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