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Transparency is the best medicine

Health Insurer Code of Conduct may improve the quality of care

Many of us entered med school for the age-old reasons generations before have gone into the profession — out of an interest in helping people and curing what ails them

As a young physician in my first months of practice, I remember prescribing the “gold standard” to one of my patients to treat his ailments, only to berated 20 minutes later because the treatment was so expensive. I explained to him he was getting the best treatment available. He explained to me he would be just as happy with the “silver standard.” Cost has been part of my medical decision making ever since.

It is getting harder and harder to provide quality care as newer barriers to access arise.  Health insurers have different policies related to generics, prior authorizations and formulary changes. The time it takes to keep up with the changes can be overwhelming to a small practice. The lack of transparency regarding those policies by insurers often adds to the confusion and frustration.  

Health providers must meet this modern challenge of providing care while still casting an eye to managing costs. Our highest priority is to deliver the best quality care to our patients. How many times have physicians chosen their second or third plan of care simply because it was covered by insurance? 

Patients deserve the best treatment possible. Physicians need to know the evidence behind health insurers’ decisions so we can provide knowledgeable high-quality care. Transparency among health insurers will lead to overall better quality and delivery of healthcare. 

Overall, the costs to our healthcare system are lower when people can afford their medicines, when they are compliant with the course of care laid out by their doctor and when access to remedies for their unique and particular needs are available.  Health insurers should be our partners in this process

Currently, an effort is under way by the American Medical Association (AMA), and will be considered in upcoming weeks, regarding a Health Insurer’s Code of Conduct.

This is a coordinated effort among state medical groups, specialty societies and comes from a decidedly physician perspective.

The goal? To challenge restrictive policies without legislative or judicial intervention. To provide data which could lead to reform. To provide patient and businesses with a way to compare the performance of health plans.

The Code would work hand-in-hand with the AMA’s recently released National Health Insurer Report Card (NHIRC), which evaluates claims processing.

A Code of Conduct should consider the following areas:

Clinical Autonomy — Allow physicians to make decisions without artificial barriers such as prior-authorization. Formularies based on appropriate clinical evidence. Protecting patients from sudden changes in formularies.

Transparency — Disclosure regarding ranking systems. Disclosure of incentives to health plans, contractors and providers. Disclosures regarding reimbursement and factors affecting changes in prescriptions.

Corporate Integrity — Business practices that do not negatively impact patient/physician stakeholders, avoidance of conflicts of interest, fair and timely reimbursement.

Patient Safety and Welfare — Real simple. Patients before profits.

There are a number of issues which must be addressed, which include, but are not limited to: Involvement of insurers in the implementation of this policy, consumer involvement and monitoring compliance.

The outcry is building and it is only a matter of time before reform is a reality. Better to meet the challenge head on in crafting good policy which integrates concerns for all parties.

Physicians have a code of conduct of sorts. It’s called the Hippocratic Oath.  Many physicians recite it when they graduate from medical school. Part of it goes something like this, “I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.”   I couldn’t have said it better myself.


Jennifer D. Gholson, M.D. is chief medical officer for Information & Quality Healthcare, Mississippi’s Medicare Quality Improvement Organization and president of Gholson Healthcare Consulting, LLC.


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