Opinion Column

Legislation Needs “Any Willing Provider”

The Senate health care reform bill contains none of the features needed for real reform. The principal lobbyists have all scored impressive victories.

The Wall Street “greed is good” sector, otherwise known as the commercial insurance business, traded obscene profit-making on its Medicare Advantage products for a legal mandate that will force tens of millions of uninsured to buy their insurance products at their prices. The pharmaceutical industry protected its turf once again from the evolutionary pressure to make it accept some sort of payer-based fee schedule like all the other health care providers. Major hospital systems across the nation agreed to a minor reduction in the expected future increase of Medicare payments in return for a batch of goodies, among them: no significant changes in reimbursement methodologies, which would have punished over-utilization.

Since I despair of the possibility we will get true health care reform legislation, I propose a fallback position. There is one small insurance reform that would effect real change in health care but it is not in the bill: an “any willing provider” mandate.

This would allow a patient to choose any doctor willing to accept the fee paid by the patient’s health insurance, even if the doctor is not in the insurer’s network of approved practitioners. Patients whose employers change insurers can keep their doctors so long as they agree to accept what the new insurer pays. The corollary benefit of “any willing provider” is increased economic independence for primary care physicians who otherwise have to affiliate with large hospital systems because those systems have leverage in negotiating contracts with insurers.

Some states have such “any willing provider” laws, but national action is needed to help end wasteful spending. The engine driving dramatic increases in the cost of health care in this country is utilization. For-profit insurance companies are engineered to make money every time a patient sees the doctor, has a test or procedure done, or takes a drug. Pharmaceutical company profits are tied to the number of prescription pads used up by physicians. Hospital systems are fed by specialists encouraged to practice their specialty early and often.

In order to reform health care and decrease over-utilization without imposing rationing by a bureaucrat-prompting hysterics about death camps-there must be a healthy supply of well-compensated, independent general practice physicians. General practice physicians with long-established patient-doctor relationships “ration” health care the right way. They know the patient, the patient’s history, the patient’s family and the patient’s job, lifestyle, stresses, goals, etc. They are better situated to work with patients to maintain good health. They know when to make a referral to a specialist and they know when to tell a patient, “Let nature take its course.” Few interested in legitimate reform of health care would argue the point or deny the importance of an increased emphasis on general practice, primary care.

How would an “any willing provider” provision in the insurance reform legislation help? The health care system in this country is dominated by large insurance companies and large hospital systems. Primary care physicians are reduced to doormen by the system. Patients are reduced to covered lives. The system does not value the patient-doctor relationship. The system values numbers, profits, “covered lives” and contracts.

Note I did not refer to primary care physicians as “gatekeepers” because they are not encouraged to keep the patient at their gate. Primary care physicians are “encouraged” to show patients through the door into the system, to order tests and, based on those tests, to refer patients into specialists inhabiting medical towers filled with expensive technologies. Neither the patient nor the primary care physician has a real choice regarding whether the test will be ordered, whether the referral to the specialist will be made, or — and this is the key restriction — which system will be chosen. The insurance-provider contract, the managed care network, will determine where the patient goes. The primary care physician-patient relationship is not permitted to function outside the contracted network. The physician has to feed the network in order to survive.

If the law of the land protected the primacy of the doctor-patient relationship by allowing them to establish and maintain that relationship without regard to insurance and provider network contracts, primary care physicians would be more willing to exist and practice independently. As it stands now, primary care physicians risk being out-of-network, effectively cut off from patients, unless they align with a system large enough to negotiate decent contracts with large insurance companies.

It is difficult to present a rational argument against an “any willing provider” rule, since it obviously reduces outside interference in the sacred doctor-patient relationship. The president promised that he would not sign a bill that made Americans change doctors, but this bill does nothing to protect the doctor-patient relationship. The rule would be a simple thing to do, at no cost to the taxpayer and would have a profound impact on health care. It would begin to level the playing field, increase competition and encourage the independence of general practice, primary care physicians.

Would an “any willing provider” provision make the Senate bill a good piece of reform legislation all by itself? No. On the other hand, it would give us a small moral victory. It would be a sign that our politicians are not completely controlled by corporate profit mongers.

Paul Taylor is the CEO and chief legal counsel of Ozarks Community Hospital, a for-profit regional health system that is based in Springfield, Mo., physician-owned and serves a large number of patients who are uninsured or covered by governmental programs. He has a position paper and writes a blog.