When the American Medical Association recently released a 10-point "Code of Conduct" for health insurers, the public reaction from payers was pretty passive and politically correct.
"We do adhere to the code of conduct principles as outlined by the AMA. In fact, we have been doing so for quite some time," said Ross Blackstone, spokesman for the Health Care Service Corp. Other industry representatives issued similarly tame defenses.
But privately, some people in the health insurance industry have been much less welcoming of the AMA's 10 commandments. "I won't practice medicine if you don't practice actuarial science," one insurance consultant said.
Payers and physicians have a long history of bad blood, and the AMA's somewhat aggressive code didn't do much to improve relations.
A few of the points in the code—relating to rescissions and spending on medical services—were already covered in healthcare reform legislation. Others, such as a request for "respectful relations," seemed like vague potshots. There were, of course, valid criticisms in the code, particularly when it comes to administrative simplification and physician relations. But on the whole, it seemed like one segment of the industry simply airing its grievances with another.
What if, as a person in the insurance industry suggested to me, payers wrote their own code of conduct for physicians? Based on feedback from a few industry representatives, it might look something like this:
1. Engage in fair billing. While the majority of physicians already adhere to this point, the same could be said for insurers and some points in the AMA's code of conduct. There are, however, a few bad apples that over-bill or sometimes commit fraud.
2. Disclose conflicts of interest. "Physicians should be subject to the same transparencies as the insurers. Patients should have a right to know whether or not their physician owns the imaging center where they are sent for their CT scan, should know how much their physician is charging for their cardiac cath, etc.," says Peter Gurk, MD, medical director for Bluegrass Family Health.
3. Learn the business side of medicine. Insurers often have the best relationships with physicians who understand the business aspects of managed care and are willing to partner with their payers.
4. Embrace the evidence. The AMA requested that medical necessity be defined as care a prudent physician would provide in accordance with "generally accepted standards of medical practice." But that doesn't necessarily mean evidence-based care and could include practices that are commonly practiced but not necessarily the best option.
If a group of health plans released a code of conduct for physicians, would that accomplish anything? Probably not. And it's unlikely that the AMA's code of conduct will, either. Again, the physician organization had some valid criticisms, but the delivery of the message only makes public the wedge between the two groups.
Blame doesn't lie solely with the AMA. Both groups have to overcome a rocky history and learn to work better as partners. Gurk, who has worked both as a physician and for a health insurer, offers the best advice: "Drop the adversarial relationship on both sides."