Physician specialists, including orthopedic surgeons, often have tumultuous relationships with payers, seeking less prior authorization requirements and higher reimbursement rates.
Here is what 6 key orthopedic and spine leaders have said about major insurance companies so far in 2024:
Alexander Vaccaro, MD, PhD. President of Philadelphia-based Rothman Orthopaedic Institute, on its value-based care partnership with Independence Blue Cross: The data has shown that value-based care works. Here at Rothman Orthopaedics, we are proud to work with Independence Blue Cross on this model, and we will continue to look for ways to build upon this approach for their members.
Mick Perez-Cruet, MD. Leader at The Michigan Spine Surgery Improvement Collaborative, on the benefits of data collection initiatives in healthcare: Expanding nationally hinges on securing resources like grants or insurance coverage for Abstractors. Blue Cross Blue Shield supports us in Michigan, but similar funding would be essential elsewhere. Demonstrating savings to Medicare and Medicaid could encourage federal support for scaling this model.
Michael Havig, MD. Orthopedic Surgeon at Naples, Fla.-based OrthoCollier on value-based care's stumbling blocks for insurers and Medicare: When you talk about value-based care, you need to break it down into the simpler components of what is a bundle of healthcare? What's that bundle cost? What does that bundle include? Traditionally healthcare has been retrospectively priced. You go see the physician, they do a bunch of things, and they add up the cost of all those things. Let's say it's $1,000 but Medicare pays $150 for that and Blue Cross pays $200. It's just confusing to everybody. I think if an employer or a payer asks, "What's the cost to have an annual checkup?" it doesn't seem like that would be that hard to put a price on. But you really can't find transparent pricing for that 99% of the time. The same thing with specialty care.
Brian Gantwerker, MD. Neurosurgeon at The Craniospinal Center of Los Angeles: As we have seen from the latest tomfoolery of United Healthcare overcharging the government to the tune of $8.7 billion, the government is not interested or serious about saving money.
So a physician pay cut, amplified not only by inflation but also in the context of previous cuts, is clearly designed to drive physicians out or into employment. By making fee-for-service untenable, they seek to implode the current system to use it as an excuse for single payer.
Most of the mandates and benchmarks since the inception of the ACA, completely unfounded, have never been shown to improve patient safety nor improve quality. Again, these were placed not to get patients better care, but to make things harder for mom and pop practices to exist.
The net effect will be that if you amortize out the cost of rent, employee salary, malpractice, insurance, and general office expenses, it will be a net negative to see Medicare patients. The idea here is to decrease access and demonized doctors for "being greedy." This carries the narrative that doctors drive up the cost of care, which at this point is laughable since we are down about 20% to 30% from about 30 years ago. The only thing that's really gone is insurance premiums and the cost of medications. You don’t have to realize which way the wind is blowing.
A lot of misguided policy and frankly people who used to work in insurance companies that are now inside the government are driving profits to their old colleagues. They are neither serious nor honest about wanting to save money or provide better care."
Rick Gawenda. Chair of the Payment Policy Committee of the Private Practice Section of the American Physical Therapy Association, on the exclusion of physical therapists from UHC's new gold card program: You know, obviously it's disappointing, No. 1, to see that PTs are not eligible for the gold card program. Would I be open to it? Sure, but I think we would need to know the rules. And obviously, UHC is really not being forthright and transparent on how an organization becomes eligible for the gold card. They're not telling you that. It's just right now, you just log in and find out, are you in or are you out. So again, if the only way to get into a gold card is by limiting how often you treat a patient, and you're doing that so you can be in a gold card program to get away from prior authorization, but yet you're not serving your patients, right?
Robert Hall. Senior payment consultant at APTA Private Practice, on adding extra prior authorization requirements for physical threapy: I think the gold card plan is like putting lipstick on a pig, right? I mean, the idea that we're going to go back to prior authorization for this high-volume service of physical therapy and then say, "Oh, look what we've got to cover, because we've got a gold card program." It's a huge leap backwards. Last year, UHC said they weren't going to be doing prior authorizations. There are repercussions to unjustified change. I don't know what the justification is for this, right? I mean, why are they coming out and saying "We need to do this now.