Managed Care - March 2008 - (Page 22) THIS DOCTOR BEGS TO DISAGREE N ot everyone is enamored of Harvard Pilgrim Health Care. CEO Charlie Baker says that the insurer tries to limit the hassle for physicians. Well, try harder, suggests Purnima Sangal, MD, a gynecologist in Chelmsford, Mass. She finds working with Blue Cross Blue Shield of Massachusetts to be much less problematic. Even the state’s cumbersome Medicaid program, MassHealth, is easier to deal with, says Sangal. “Patients come to me and I am not very concerned about what insurance they carry,” says Sangal. “It’s only when my billing manager will come back to me with a lot of issues on different claims. Harvard Pilgrim is the one that is the worst.” No one suggests that the complaints sounded by Sangal, referred to us by the Massachusetts Medical Society, amount to anything more than anecdotal evidence — one physician’s opinion. After all, the MMS’s view of Harvard Pilgrim is much less harsh. Still, at the very least, Sangal’s reaction suggests that there’s room for improvement in even the best health plan. Her focus is payment of claims. She gives as an example a woman who comes to her to confirm that she’s pregnant. “Within a week, she miscarries on her own. Harvard Pilgrim will deny the claim, saying, ‘We want the tissue report.’ The lady miscarried on her own. I don’t have any tissue.” Harvard Pilgrim’s reaction? The health plan resolved 99.3 percent of all claims within 30 days in 2007; so far this year, it resolved 99.6 percent within 30 says, says CEO Charlie Baker. “We survey physicians and hospitals on our operational performance annually, and if we discover problems, we make adjustments. Ninety percent of the providers we surveyed last year were satisfied with our overall performance. And I always ask how we’re doing when I meet with physician and hospital leaders, and if they raise issues, we try to resolve them. “Harvard Pilgrim processes over 10 million claims a year and seeks additional clinical information on about 15,000 claims a year — about one tenth of one percent, which doesn't seem like a particularly significant administrative burden.” Barbra Rabson, executive director of Massachusetts Health Quality Partners (MHQP), a broad-based collaborative that measures and reports on physician performance, disputes that assertion, saying that the Massachusetts plans do in fact share some information under her organization’s auspices. “It’s fair to wish for more, but there’s so much more [in Massachusetts] than in other places.” The fact that the highly rated Massachusetts health plans are all not-for-profit does not mean that what they do cannot be duplicated by a for-profit plan, says Baker. “I don’t think there’s any reason why any plan, for-profit or not-for-profit, can’t be focused on reducing errors in transaction activity with physicians and hospitals.” do better,” says Magee. “We’ll be able to move forward and improve the care that we deliver.” Sometimes, though, Magee wishes that there were less competition. “Our efforts to try to get the plans to deliver information in a uniform way to physicians so that they can pool it and use that electronic data to improve care have not met with success,” says Magee. “Part of it has to do with the fact that they feel a certain pressure to distinguish themselves.” Regional power Besides, Harvard Pilgrim’s success has less to do with it’s being a not-for-profit than it does with being a regional health plan, says Rabson. “There are some challenges with big national health plans playing a really strong collaborative role within different regions,” says Rabson. “If you’re an independent plan in that region, that’s your market area so you’re committed to it. We’ve had this experience a little bit with MHQP’s collaborative guidelines across plans. Although we have been successful in getting some national players to endorse, it’s tricky because sometimes they say, ‘We don’t want to endorse different guidelines for different regions. We want to be centralized.’” Says Herman, Harvard Pilgrim’s CMO: “It’s a very different experience for me if I know that I’m going to bump into some of these folks in the supermarket. If I get sick, they’re the ones I’m going to be calling. The very long arm of the national player is just a fact. ” Ultimately, though, it’s about the pursuit of perfection. Baker says that in some industries, a 5percent error rate may not sound so bad. “If you’re processing millions of claims, it’s a ton of rework,” says Baker. “You’ve got to get that number down to zero, or something close to zero.” MC 22 MANAGED CARE / MARCH 2008
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