Editorial: Taking on 'Big Insurance' -- One Health Plan at a Time

You may have noticed a pattern when you scanned headlines like these recently in AAFP News Now: "Anthem Blinks: Blended Codes in Ohio to End in September" … "Academy, Humana Exchange Ideas, Clarify Views" … "AAFP Asks CIGNA to Rescind Unfair Payment Policy" … "Aetna Modifies Policy Regarding Bundling of E/M Codes."

It's the pattern woven by AAFP's private sector advocacy effort with health plans on your behalf. As an individual family physician, you've probably felt like David confronting a host of insurance Goliaths: They're big, they're bad -- and all you have is your tiny little slingshot!

But when the Academy steps forward to speak on behalf of all 94,000 AAFP members, something magical happens. The Goliaths stop. They listen. And some of them actually change their behavior.

The Academy's tangle with UnitedHealthcare over the insurer's benefit tiering program is a case in point -- and a good example of how long it sometimes takes to see results. In April 2005, a strongly worded letter to United from the Academy accused the program of being "less about providing legitimate information to inform patient decision-making and more about directing patients to low cost physicians using questionable information and methodology." The letter asked United to suspend implementation until the program's "serious flaws" could be addressed and offered to meet with United on the issue.

Goliath stopped. It thought. It came to AAFP headquarters in May 2005 to listen. And it ultimately changed its behavior.

In January 2006, United's representatives returned to AAFP headquarters to say the giant had decided not to support benefit tiering around primary care in its new UnitedHealth Premium^SM Designation Program. They praised Academy leaders and members for feedback that led to the decision. And they listened while AAFP leaders aired concerns about other issues. "This is an ongoing process of engagement and collaboration that I hope will deepen and strengthen over time," said United's EVP of clinical strategies and policy after the meeting.

In addition to fighting solo, the Academy often works with others to bring about needed change, as chronicled in a recent AAFP News Now story about Anthem Blue Cross Blue Shield of Ohio. Problems with other insurers are on the Academy's radarscope as well.

How can you help? Keep telling the Academy about your experiences with insurers. It's easy to do via the AAFP's health plan complaint form. Then be patient, and watch AAFP News Now for updates as the Academy uses the ammunition you provide in its battle with the Goliaths.