Lake Wobegon, Where All The Doctors Are Above Average

September 25, 2009
Alan Berkenwald

Welcome to the brave new world created by health insurance companies in Massachusetts—where all the doctors are to be above average—or their patients will be financially punished.

Garrsion Keillor's fictitious town of Lake Wobegon, existing in the minds of his National Public Radio listeners, is a place where "the women are strong, the men good looking, and all the children are above average."

Welcome to the brave new world created by health insurance companies in Massachusetts—where all the doctors are to be above average—or their patients will be financially punished.

Going by the name of "Tiering", this is a brilliant scheme that could only have been invented by Wall Street financiers or Bernie Madoff. It runs something like this: if your physician is in Tier #1—top tier—your co-pay is unchanged; if Tier #2, your co-pay goes up by around $10; Tier #3, co-pay goes up around $20. The message to the patients, explicit and implicit, is that your lower tier doctor is practicing lower quality medicine, so find a Tier #1 physician, get better care and save money.

Naturally, as the patient pays a larger co-pay at the door, the insurance company gets to pay less of the total office charge. Long suffering Massachusetts physicians are told, "Hey, you get the same total global fee, so no problem. Work smarter and our secret proprietary quality review will place you in Tier #1 and your patients will love you."

Brilliant. All is well in Lake Wobegon. Money moves the market and mobile consumers (ie, patients) will drive bad doctors out of practice.

Except that the Tiering curve is fixed. Only the top 20% is Tier #1, the next 60% is Tier #2, and the bottom 20% is Tier #3. The 'Tyranny of the Bell Curve,' its power now harnessed by insurance companies, gives legitimacy to a scheme that saves them money on 80% of out patient visits. The fixed curve put the fix in on this plan. For every doc that moves up into the top Tier, another one is bumped out. Oh, and 80% of patients now pay more for each visit, thanks to those lower quality physician scoundrels.

Try explaining that to your patient who is asked to pay more at the door. Explain how, after an insurance company "quality review", you were found lacking and thus demoted. Your patient still not happy? Feel free to find a top rated Tier #1 physician (if you can) and save some money while getting "higher" quality care. After all, 20% of them are out there, somewhere.

In next week's column, how healthcare insurance companies will soon guarantee that all Massachusetts physicians will have longer and narrower fingers, to facilitate and improve the quality of rectal exams. Or double your co-pay back.

alan berkenwald, md