Rationing access: Dangerous and profitable, but Is It unprofessional? by: Pamela Moore, PhD

 

Physicians have long wanted better control over managed care. Now, some are making it happen by controlling access: They are letting patients with high-paying or fast-paying insurers get appointments quickly. Those who use a low-paying HMO get in too -- eventually.

The strategy can pay off for practices with monopolistic market shares -- primarily specialist groups -- and weak contracts. For others, it may be too risky.

 

The strategy

Mike Pulaski, CEO for Peachtree Orthopedic Clinic, a 24-physician musculoskeletal practice in Atlanta, credits the technique, called "rationing access," as one of the contributing factors for a 23 percent jump in profit over the past year.
 

"I can't tell you how important it is to set aside the payer mix you want," he says.
 

Appointment schedulers in Pulaski's practice make no fuss about asking callers who insures them.
 

"If it's Skinflint Insurance, our first available appointment may be 120 days out," Pulaski explains.
 

And no patient is guaranteed an appointment; Peachtree Orthopedic Clinic reserves the right to cancel an appointment 72 hours in advance if there's a problem with insurance or referral verification. All appointments open up 48 hours in advance.
 

"It's just like filling airline seats," he says. "You fill up the premium seats with your best-paying customers then open it up 48 hours before takeoff to get a full plane."

 

An ethical policy?

Other Western, industrialized nations control access and payer mix, Pulaski stresses.
 

"There is a direct relation between payment and access in Sweden, Canada, and the UK," he says. "The physicians and members of these societies do not consider it unethical that access is restricted."
 

The policy impacts access, never treatment. Once patients are there, everyone is treated equally. Moreover, the front-office staff, not physicians, controls the appointment books. Effectively, the policy makes no difference to the physicians in terms of care quality; it only makes a difference to their bottom lines.
 

"The reality is that the airlines [ration access] and banks do it by rewarding customers with big balances with better loans and rates," comments Claire Brockbank, strategy and communications officer at C3Med, Denver. "Why shouldn't that be OK in healthcare?"
 

As shocking as the concept may seem at first, it's one most people readily accept in other fields.
 

"It's a pretty slippery slope," Brockbank says, adding that as long as there is no impact on care quality, the Hippocratic Oath is not in question.
 

Pulaski sees his plan as fair play in managed care.
 

"There are some contracts out there that are just hideous," he says.

"They pay 30 percent of the time at 50 percent of RBRVS."
 

Still, many of his payer contracts require him to give access to their patients just like he gives access to all others. Pulaski figures he satisfies that requirement by rationing all payers. In fact, he is so sure of being within his rights that he went to his major payers and boldly announced his plans. The payers are not exactly thrilled, he admits, but the specialty practice has a large enough market share that Pulaski is not afraid of losing low-paying contracts.
 

Primary-care practices, or those with less market strength, would not be so lucky.

 

Tide turning on access

Indeed, any practice with better-defined access clauses in its payer contracts might be in serious trouble if it tried to ration appointments -- more so as access becomes more and more important for payers. At Fallon Community Health Plan in Worcester, Mass., for example, physician practices are expected to provide routine physicals and new patient appointments within 30 days and urgent care in 48 hours, according to Cleveland Davis, physician services specialist.
 

"Our employers are demanding [fast appointments]. Because the demand is placed on us, we turn around and throw it to the physicians," he says, adding that they do this despite the fact that most physicians consider Fallon a slow payer.
 

The plan offers consulting to practices having trouble meeting the goals. Davis "doesn't doubt" that access rationing is happening, but warns that "if we found out that a physician is doing that, we don't care if he's popular, we would terminate the contract."
 

Scott Keim, vice president of network management for PacifiCare of Colorado, agrees: "I understand there are economic realities," he says. "But for an office to contract with all payers and then segment out patients based on their payer is unprofessional."
 

Pulaski thinks such bravado is out of place; he thinks insurers want to take advantage of physicians' high moral code without taking on any such responsibility themselves.
 

"Lowball insurance companies are banking on the fact that their patients will be treated equally for access and treatment. They're forcing their way in. I'm just trying to force them out," he says. "It's time for physicians to manage managed care."

 

Pamela Moore is senior editor, practice management, for Physicians Practice Inc.