Finding Common Ground: The Physician, Hospital, and Payer Working Together for the Patient

The voices calling out for a “patient-centric care model” are either rapidly fading or are being drowned out by the noises of poor payment, preauthorization, overutilization, and low-value care.

How did we get here? In this equation, there are four major players:

1. The Patient;
2. The Physician;
3. The Hospital; and
4. The Payer (if insured).

All four have varying perspectives and expectations of healthcare.

First and foremost, patients want safe care. Secondly, they want timely access, and third, they want this at a reasonable price. Most expect, very reasonably so, that the rest of the players in the equation will work it out among themselves and figure it out.

Yet, have we?

Moreover, patients expect their doctors to understand the basics of the current healthcare payment system. They usually have to deal with this complicated system at the worst possible times of their lives.

What do physicians want? Incidentally, the same thing! Also, physicians expect that the system to be set up appropriately and that it will allow them to simply practice medicine with autonomy. When insurances have processes like preauthorization and denials, right or wrong, it can feel like an attack on that autonomy. Yet in some cases, it is reasonable for the payer to know about the appropriateness and necessity of medical care, to ensure that they are footing the bill for the right care.

I think most of us still believe in the inherent goodness of people and do not believe that insurance companies are putting those roadblocks up intentionally in patient care purely for the sake of profit. I believe that they also want the same things as patients and providers. I believe their objective is to optimize utilization towards high-value care – and that, as a result, will lead inherently to controlling the cost of care.

Then what is missing?

Renowned playwright and critic George Bernard Shaw once said, “The single biggest problem in communication is the illusion that it has taken place.” Insurance companies feel that all their rules and regulations are truly helping patients, and all the information is reaching providers. The providers feel that they are not being heard, and generally respond by fighting back with the first person who speaks about it. And those people are generally hospital administrators, who are then forced to take a polarized position of taking one side or the other, leading to poor financial sustainability on one hand, or heavy-handedness towards front-line caregivers on the other.

How to resolve this? What if I told you that there is an underutilized place and time in the hospitals to enhance that communication?

That place is called the utilization review committee, and the role that can help every player in the equation is a physician advisor.

I would like to propose bringing back the patient-centered care model with the “Goyal model of value enhancement.”

Start with a few simple rules:

• Engage hospitals and physicians via the Utilization Review Committee;
• Find allies, especially value-oriented physicians on the medical staff;
• Encourage the hiring of physician advisors for every hospital; and
• Develop partnerships for cooperation, with patients at the center of every interaction.

At a tactical level, I would suggest that payers encourage and help fund the physician advisor role in hospitals to have a functioning Utilization Review Committee, which, with proper structure and oversight, can achieve the goal of putting the patient at the center – not favoring the payer nor the hospital. This can be accomplished in a budget-neutral or budget-friendly way by calculating the number of patient-days for each payer, assigning one unit of incentive for every 65,700 patient-days as a baseline, then multiplying that percentage by the physician advisor’s annual salary.

For example, if payer “Combined Health” has a panel of 20,000 patients, and 2,000 had needed hospitalization in a given year, with average length of stay (LOS) of three days, then the patient-days are 6,000. Assuming the salary, benefits, and incentives for the physician advisor was $400,000, by the Goyal model, to promote this, Combined Health would be contributing (6,000/65,700) X $400,000 = $36,530 per year.

This is less than what any company spends on a billboard. With the patient at the center of every utilization decision, and a physician advisor advocating for that patient, based on the evidence, promoting high-value care and targeting the appropriate goals of care, there would be less need for utilization staff on both the payer and provider side.

The benefits of this change would span all levels of healthcare. Imagine, for example, the savings on reducing the number of low-value care MRIs that can be achieved with a data-driven approach. Imagine how much time and money can be saved in status appropriateness if both sides work together at the front end, rather than at the back end, fighting over denials and appeals. Change is often slow and incremental, but the Goyal model could provide one of those substantial leaps that can bring the patient-centered care model back sooner rather than later.