Doctors and health insurance companies are like oil and water, or so both sides may think. But upon closer review, they are actually more alike than not, and the key to improving the health care system is a cooperative effort from both sides to make it work.

After 20 years of medical practice and spending the past three and a half years as a medical director at UHA Health Insurance, I’ve gained some insights from both perspectives.

Both doctors and health insurers have a common goal — to keep people healthy. For the medical profession, this is based on the reason many of us went into medicine in the first place, to heal people. There is a personal satisfaction in being able to help someone recover from an illness, and it’s even better when they are well enough to say thanks the next time they come into the office.

For insurance companies, it might be based on the financial motivation to keep people out of the hospital and keeping costs down for their care. But there are nurses and doctors who work for the company as well, and their goals are the same as those treating the patient — to keep people healthy and enjoying productive lives.

Ninety-eight percent of the providers are doing the right thing. It’s the 2% that ruin it for everyone else.

Taken at clinic
The vast majority of doctors are keeping costs down but a few outliers are causing problems by excessive and unnecessary billing. Getty Images

For doctors, almost all of the providers I know are not being paid extra to give intravenous medications as opposed to pills for their patients. Most of the visits are medically necessary, and patients are only being seen when they need care. They are not told to come weekly for chronic conditions that don’t need to be monitored that often. They aren’t given medications that they have to pay cash for in the office.

However, there are always a few outliers that seem to bill insurance companies at the highest level for each and every patient every time, and sometimes see patients way more often than they need to, or prescribe medication that isn’t appropriate. The only conclusion to come to is that they do it for the money.

Insurance companies are forced to create programs to monitor those providers, because it’s not fair for everyone else that pays their premiums to have their money spent on visits or care that aren’t necessary. That might increase the burden of documentation for those doctors who are doing the right thing, as they get caught up in the process of finding those who are not as forthright.

The cost of care is something everyone should know but few of us are able to really calculate until the service is completed, if then. Doctors don’t know what things cost, unless it’s just their own office visit. There are so many variables if someone goes to the hospital.

It’s impossible to know in advance what the cost could be. Everything is charged individually, and there are complex arrangements between hospitals, insurance companies, participating doctors and more. Patients might ask about their share of the bill, but it’s often too complicated to answer that question directly.

Insurance companies might know their particular rates for certain procedures, but it’s hard to know in advance if there are any complications that might require additional medications or care. That’s why “how much will this cost” is almost impossible to answer.

Significant changes have happened in the medical world in the past few years, and more challenges lie ahead.

But if hospitals and insurance companies combined efforts to establish a “case rate” for a condition, it might take the guessing out of how much a procedure costs. It would be the same regardless of what is done. But this requires a lot of mutual trust, and alternatives for when this doesn’t work out well, so that neither side is penalized in the process.

Higher costs affect everyone. Doctors are given set rates for reimbursement for Medicare and Medicaid. Private commercial insurance companies like HMSA and UHA also set payment to their participating providers.

Insurance guidelines require that 85% of the overall premium dollars be spent on health care costs. That means if the amount of reimbursement to the providers goes up, then premiums will also rise. If expensive medication is prescribed, the cost of care goes up and that is directly related to the insurance premiums increasing.

Even after 20 years in medicine, I still am baffled each January by all the formulary changes from all the different plans. If I don’t understand it, I can’t expect patients to either. Insurance companies, doctors and patients all need to work on this one collectively.

Hawaii has a shortage of doctors but we do have amazing physicians right here at home who are more than capable of handling almost every medical situation that can arise. With few exceptions for procedures that we do not have available here — like bone marrow transplants — the level of care that we have locally is comparable to what might be found on the mainland.

Doctors want to have their patients stay here for their care, and take advantage of the family support that is essential to recovery. It’s a lot harder to coordinate care across the ocean, and to know what to do when patients come back home.

Insurance companies want to have patients stay here as well. It’s generally less expensive, but it’s also in an effort to support the local medical community as a whole, including the home health agencies, nursing care, physical therapy, and more. The more business we keep here in the islands, the better for all of us who live here.

Significant changes have happened in the medical world in the past few years, and more challenges lie ahead. Without a coordinated vision for the success of our health care systems on every island, along with adequate support from the insurance companies who collect the premiums and provide the payment for services, the system will not survive long term.

Doctors and insurers have to see past their differences and focus on their common goals to help support patients in the quest for better health. Having seen the system from both sides in the last few years, I am convinced that we have the leadership needed to solve this monumental challenge to create a better health care community for this generation and the one to come.

After all, our lives truly depend on it.

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