Dealing With Providers Always Takes Balance

John Marcille

The symbiotic relationship between insurer and provider has often made an unexpected turn or unforeseen detour. One new influence points this way, another that way, and who can blame insurers who pause before proceeding?

Our cover story examines the recent work of the United States Preventive Services Task Force. As contributing editor Michael D. Dalzell points out, the Affordable Care Act seems to have increased this panel’s influence. The rulings the USPSTF has made in the last few years have certainly increased its notoriety.

Mammograms? PSA tests? From such buzzwords spring alarmist headlines. What the USPSTF says is often what health plans have been telling providers for years. Is that test really necessary? But for many of these examples, a nudge still might be as far as it goes. Payers who refuse to pay for what some member or provider considers a life-saving test, despite all the evidence to the contrary, sometimes find themselves the subject of a special report on the nightly news.

So insurers in this instance are happy to step back and let providers take the lead — if you can find enough of them.

As we were going to press, the Medical Group Management Association predicted that the United States faces a shortfall of 100,000 primary care physicians by 2020. Those med students are not getting with the program.

Meanwhile, a study in the journal Surgery says that surgical “never events” in fact happen about 4,000 times a year in hospitals. The obvious examples are noted: towels and sponges left in patients or the wrong body part being operated on.

Health plans will not look the other way when it comes to these problems, nor should they.

Providers: You can’t live with them, but you can’t live without them.

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