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Physician Abrasion: A Subtle, Yet Important Issue for Payers

The relationship between physicians and insurance companies has always been complicated. While the ultimate goal of these groups is the same -- improving patient health outcomes through quality care -- the paths to achieving this goal can be very different.

Varying perspectives on data use, costs, medical necessity and reimbursement can sometimes cause friction between physicians and payers and foster a strained rapport. In particular, payer actions and activities can inadvertently impact physicians negatively, resulting in "physician abrasion."

What is Physician Abrasion?
Physician abrasion is the concept that a payer's relationship with a physician may be negatively influenced by certain activities or circumstances. A few common causes of physician abrasion include repeated – and seemingly random – payer requests for patient charts and data; complex and lengthy pre-authorization processes; slow or inconsistent claims payment; and automatic and unwanted patient assignment, which is when an insurance company assigns a patient to a physician instead of having the patient choose his or her physician.

Over time, these circumstances can wear on the physician-payer relationship and cause irritation, frustration and even hostility. If not addressed, physician abrasion can eventually undermine a patient's perception of the provider as well as the health plan, potentially resulting in member disenrollment and lower quality ratings (particularly important with Medicare STAR quality ratings impacting plan reimbursements).

The Implications of Physician Abrasion
The consequences of this abrasion vary depending on the situation and the players involved. One of the most damaging effects occurs when a frustrated physician inadvertently conveys a negative impression of the payer to the patient, affecting the patient's care experience and perceptions of the payer. Consider the example of a physician who is unhappy with a payer's pre-authorization process for total knee replacement. The physician may subconsciously communicate to a patient the difficulty in obtaining permission to perform the surgery. This could portray the health plan as inflexible and unwilling to support the patient's care needs, potentially damaging the patient's affinity with the payer.  

Another problem results when payers have inefficient processes for chart retrieval and data acquisition. Frustrated by frequent, high volume chart requests that overwhelm day-to-day operations of the practice, a physician may decide to limit payer access to medical records or not cooperate with the data acquisition process. Payers depend on these medical records to meet HEDIS (Healthcare Effectiveness Data and Information Set) and risk adjustment requirements. Without regular access to the records and cooperation from physicians, executing these critical efforts becomes very challenging.

In extreme cases, physician abrasion can cause a physician to end his or her relationship with a payer, feeling it's better to terminate the alliance than navigate the payer's rules and regulations. The loss of a physician can be quite detrimental to a payer because the physician represents a valuable source of potential members. If a large physician group terminates its association, the payer may not only lose access to potential members but also critical providers that support effective patient care.

While physician abrasion is a top worry for payers, another unfortunate byproduct of physician abrasion is member abrasion. Frustrated physicians can lead to frustrated members, which can eventually cause member dissatisfaction and attrition. In most cases, patients have a relationship with their physician that is closer than that with the payer. After all, patients see and interact with their physician on a more personal level: the physician is one individual instead of a "faceless" company. As a result of this bond, patients place great importance on the opinions of physicians. If physician opinions are less than positive, then a payer's affiliation with a patient could be on shaky ground.

Don't Discount the Problem
Physician abrasion is not something to dismiss or ignore. Once rooted, the problem becomes more difficult to resolve. There is good news, however. Taking a proactive approach to addressing physician abrasion can help head off any irritations or frustrations before they become significant. Taking preventive actions such as developing an integrated process for collecting medical records for both HEDIS and risk adjustment purposes at the same time; streamlining pre-authorization and pre-certification processes; and ensuring prompt and consistent claims payment can mitigate abrasion and even promote a positive dynamic with physicians. Just as a negative relationship can undermine patient care efforts, a positive one can enhance these activities, resulting in a partnership where physicians and payers work together to deliver the best possible care for patients.

Rolland is the SVP, Product Development for Medicare Advantage at Outcomes Health Information Solutions.