In 2007, Senate Bill 1731 was enacted into law.  This law requires health plans to notify enrollees in advance of services that facility-based physicians may not be contracted with the health plans and that the patient may billed for the amount not paid by the health plan.  This law also requires that hospitals and physicians must notify patients that they may be billed for “out of network” services, even if the hospital is contracted with the health plan.

Rep. Smithee feels that more should be done to remedy the “balance-billing” and “network adequacy” problem.  He is advocating that insurance companies make greater efforts to include hospital-based physicians in their networks and that contracted hospitals also make greater efforts to insure that at least “some” of their hospital-based physicians are contracted with any health plan with which the hospital is contracted.. He feels that responsibility for resolving the problem must be a “shared” obligation of health plans, patients and physicians.

SB1731 also directed the Texas Dept. of Insurance to collect data on health plan reimbursements and to also create a Task Force to study network adequacy issues.  This Task Force held its initial meeting in Dec., 2007 to bring the stakeholders together to discuss both network adequacy and balance billing.  Dianne Longley, Director of Special Projects for the TDI Life, Health and Licensing Division stated that the first mission of the task force is to determine what data is needed and what data is missing. Ms. Langley says that TDI wants to obtain a variety of data, such as the percentage of claims filed “out of network” and the “actual number of patients being balance billed by physicians”.  Another problem is that there is no universally accepted definition of “network adequacy”. In December, 2008, the Task Force will submit data and their recommendations to the legislature.  In all likelihood, the TMA will advocate for increased authority for the TDI to regulate “network adequacy” and for TDI to require increased “transparency” of health plans in terms of their “loss-ratios”, i.e. the percentage of each premium dollar that actually goes to pay healthcare providers.

On the first day of one of my graduate courses in college (many years ago) we spent the entire class period defining communication.  By the end of the class we settled on defining communication as the creation of understanding.  With that premise in mind we spent the rest of the semester looking at the barriers to complete understanding between people within their own organizations and outside of their own organizations.  Often leadership mistakenly assumes that a one-way expression of facts or thoughts in voice commands, memos or e-mails is communication.  However, to create understanding among people within an organization or between people in other groups takes both senders and receivers.  The sender encodes a message through the selection of words from a particular language.  The receiver decodes the message in order to understand the message the sender is trying to get across.  Finally, to make the communication loop complete there should be feedback demonstrating that the receiver “got it”.

Consistently, communication between physicians, hospitals and business people is a major challenge.  It is not just availability, or lack thereof, such as physicians with schedules at all hours all days whereas hospital or business support people work regular business hours,  but it is also perspective and perception that creates barriers to effective communication.  A common barrier to communication is preconceived thoughts or assumptions from one or both parties.  We are not as likely to be attentive if we think that we already know something that the sender is trying to convey.  By contrast if we think the other party should know some fact or concept, then we are not as likely to inquire or probe for feedback. 

Patients feels this challenge of understanding the care given by their physicians in this regard. According to a recent study in the Annals of Emergency Medicine, “A vast majority of emergency room patients are discharged without understanding the treatment they received or how to care for themselves once they get home, according to researchers. The trend could lead to medication errors and serious complications that can send them right back to the hospital, they added. In the study, researchers followed 140 English-speaking patients discharged from emergency departments in two Michigan hospitals and measured their understanding in four areas. The study found that 78% of patients did not understand at least one area and about half did not understand two or more areas.” 

Tone of voice, facial expression and rate of speech greatly impact the effectiveness of true communication. For example, some business people talk slowly (especially in the South) and in great detail whereas the physicians want to get to the bottom line quickly.  I know from experience that if I fail to quickly get to the point when talking with a physician, I expect to be interrupted within a few seconds.  It is not out of rudeness; rather it is training, everyday demands of the physicians’ time and even intelligence that causes this.  On that last quality, studies have shown that highly intelligent people generally express a high level of impatience.  Makes sense if you think about it.

OK, so what am I trying to communicate?  MedaPhase is a service organization.  We have about a hundred people processing about a half of a million patient visits per year representing millions of dollars in accounts receivable.  Everyday the challenges of communication abound on multi-platforms, within MedaPhase, with hospitals, physicians, coders, insurance companies, federal and state agencies.   Electronic claims, written statements, telephone calls, e-mails, list serves, internet sites, tele-conferences and face to face meetings all present unique challenges with each.  In one sense communication is the business that we are in.  Most paramount is the creation of understanding between everyone at MedaPhase and all of the physicians whom it serves.

To that extent we are always looking for ways to enhance better communication.  This quarterly newsletter is one medium.  Month end reports, charts and graphs are another.  A revised website is under construction incorporating more options to review data anytime day or night.  An electronic satisfaction survey is under development to enhance better feedback and reveal opportunities for improvement.  Internally, various staff members are encouraged to contact representatives at various sites to assess effectiveness.  All of this activity is in and of itself a form of communication that MedaPhase encourages the opportunity to create understanding.