The College of American Pathologists (CAP) published a white paper outlining how private health insurers are increasingly interfering in patient-physician and physician-physician relationships by inappropriately limiting the number of in-network physicians and exclusively contracting with specific providers/facilities. “Examining the State of Health Care’s Private Payers and the Adverse Impact of Insurance Interference” provides in-depth analysis of these health insurer tactics and trends that negatively impact the practice of pathology and the patients pathologists serve. The following are some examples of how private health insurers are impacting the care patients receive:
Insurance consolidation
No Surprises Act implementation
Insurer profits and third-party consultants
Steering, tiering, and other network manipulation
Reduced reimbursement and “take it or leave it” physician contracts
Non-standard coding requirements
Prior authorization and other utilization management measures
“Patients and their physicians should be able to rely on the expertise of pathologists and the availability of appropriate testing,” said CAP President Donald Karcher, MD, FCAP. “This is complicated by insurance companies that dictate and interfere with medical decisions and patient care at the local level to boost profits. In the end, patient care suffers from unnecessary intrusion by the insurance company into the patient-physician relationship.”
Health insurance plans are increasingly relying on narrow/tiered and often inadequate networks of contracted physicians, hospitals, and other providers to shift medically necessary health care costs onto their enrollees. According to a 2023 Kaiser Family Foundation survey, more than a quarter (26%) of insured adults reported that an in-network physician they wanted to see in the last year did not have appointments available and 14% of respondents said their insurance did not cover the particular physician or hospital they needed.
“Patients believe their health plan will provide them access to physicians and health care facilities in their area, but too often their plan comes up short,” said Karcher. “They may find that their insurance company is deciding what it thinks is best for a patient, through a one-size-fits-all approach that ignores the patient’s medical history, clinically acceptable practices, and quality care. As for physicians, they are increasingly being forced out of network. That is devastating in areas of the country where insurers have consolidated and represent substantial portions of the local patient population.”
The report concludes with recommendations and solutions to ensure patients and their physicians have appropriate access to pathology services for timely and accurate life-saving diagnosis and treatment, resulting in better patient outcomes.
Download the white paper here. Watch a video statement from CAP President Donald Karcher, MD, FCAP here.
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About the College of American Pathologists (CAP)
As the world’s largest organization of board-certified pathologists and leading provider of laboratory accreditation and proficiency testing programs, the College of American Pathologists (CAP) serves patients, pathologists, and the public by fostering and advocating excellence in the practice of pathology and laboratory medicine worldwide. For more information, visit the CAP Newsroom, CAP.org and yourpathologist.org to watch pathologists at work and see the stories of the patients who trust them with their care.