Patient Support & Advocacy

Payer-backed care shopping plans shouldn’t coerce patients

There are programs offered by employers and insurance companies that offer patients financial incentives when they use shopping tools to compare prices on health care items and services and choose lower-cost options.

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These financial incentive program (FIPs) can empower patients to make informed health care choices, but FIPS need to be transparent and never coerce patients to accept lower-cost care that could jeopardize their health, according to an AMA Council on Medical Service report whose recommendations were adopted at the 2019 AMA Interim Meeting in San Diego.

“With payers increasingly looking to FIPs as an avenue for reducing patient costs, it is essential that health care quality not be sacrificed in the process, and that fragmentation of care is minimized,” says the report, adding that the FIPs it describes “claim to base their decisions on care quality” but do not include metrics or data on how they evaluate quality.

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The AMA House of Delegates adopted a set of guiding principles that employers and insurance companies should incorporate into FIP design.

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Specifically, delegates adopted policy to support continuity-of-care principles be included in any FIP. Such programs should:

  • Collaborate with the physician community in the development and implementation of patient incentives, as well as in the identification of high-value referral options based on both quality and cost of care.
  • Provide treating physicians with access to patients’ FIP benefits information in real-time during patient consultations, allowing patients and physicians to work together to select appropriate referral options.
  • Inform referring or primary care physicians when their patients have selected an FIP service prior to the provision of that service.
  • Provide referring or primary care physicians with the full record of the service encounter.
  • Never interfere with a patient-physician relationship, for example, by proactively suggesting health care items or services that may or may not become part of a future care plan.
  • Inform patients that only treating physicians can determine whether a lower-cost care option is medically appropriate in their case and encourage patients to consult with their physicians prior to making changes to established care plans.

Delegates also adopted policy supporting the following quality and cost principles for any FIP. These programs should:

  • Remind patients that they can receive care from the physician or facility of their choice consistent with their health plan benefits.
  • Provide publicly available information regarding the metrics used to identify, and quality scores associated with, lower and higher-cost health care items, services, physicians and facilities.
  • Provide patients and physicians with the quality scores associated with both lower and higher-cost physicians and facilities, as well as information regarding the methods used to determine quality scores. Differences in cost due to specialty or sub-specialty focus should be explicitly stated and clearly explained if data is made public.
  • Respond within a reasonable time frame to inquiries of whether the physician is among the preferred lower-cost physicians; the physician’s quality scores and those of lower-cost physicians; and directions for how to appeal exclusion from lists of preferred lower-cost physicians.
  • Provide a process through which patients and physicians can report unsatisfactory care experiences when  referred to lower-cost physicians or facilities. The reporting process should be easily accessible by patients and physicians participating in the program.
  • Provide meaningful transparency of prices and vendors.
  • Inform patients of the health plan cost-sharing and any financial incentives associated with receiving care from FIP-preferred, other in-network, and out-of-network physicians and facilities.
  • Inform patients that pursuing lower-cost or incentivized care, including FIP incentives, may require them to undertake some burden, such as traveling to a lower-cost site of service or complying with a more complex dosing regimen for lower-cost prescription drugs.
  • Methods of cost attribution to a physician or facility must be transparent, and the assumptions underlying cost attributions must be publicly available if cost is a factor used to stratify physicians or facilities.

Delegates also adopted policy to:

Support requiring health insurers to indemnify patients for any additional medical expenses resulting from needed services following inadequate FIP-recommended services.

  • Oppose FIPs that effectively limit patient choice by making alternatives other than the FIP-preferred choice so expensive, onerous and inconvenient that patients effectively must choose the FIP choice.
  • Encourage state medical associations and national medical specialty societies to apply these principles in seeking opportunities to collaborate in the design and implementation of FIPs, with the goal of empowering physicians and patients to make high-value referral choices.

The AMA also will encourage objective studies of the impact of FIPs that include data collection on dimensions such as:

Patient outcomes or the quality of care provided with shopped services.

  • Patient utilization of shopped services.
  • Patient satisfaction with care for shopped services.
  • Patient choice of health care provider.
  • Impact on physician administrative burden.
  • Overall or systemic impact on health care costs and care fragmentation.