Ethics, Steerage, and a Level Playing Field

How you feel about the issue of patient steerage depends, of course, on whether you are the beneficiary of a steady stream of unsuspecting patients being directed your way by payors determined to control every aspect of the delivery system. If you are trying to compete with a fair market value and are not entitled to the guaranteed blocks of covered lives that are directed with regularity to your competitor, you are not likely to see such steerage as very fair at all. Shouldn’t patients be entitled to the best, the most convenient, or even the places that they prefer? The realities of today’s medical imaging business environment dictate that shifts in the distribution of patient populations are going to occur. In fact, it is likely that as payors consolidate their preferred providers based on more restrictive criteria, the playing field will likewise continue to undulate. In many markets, it will be far from level, and therein lies the questionable ethical dimension of directing patients to, say, the lowest-priced provider. A consistent rallying cry, for many years now, has been the notion of patient choice in the selection of the providers of medical imaging services, among other health care choices. In fact, many payors respect the right of the patient to exercise that choice. Likewise, the medical imaging profession has focused endless attention on the issue of determining quality parameters in each of the modalities, with an eye toward making some type of determination of the provider’s ability to meet certain standards as the price of entry into the referral stream. Circumventing the Loop What is not often discussed in polite company is how these quality standards and patient-choice models often are circumvented in the continuous loop of a payor-provider network, which sends the patient from one entity to the other within a closed system that benefits financially at each point in the encounter. Self-referral takes many forms, and this is but one more. Nobody likes a monopoly, unless of course you happen to be the one doing the monopolizing. It’s better to compete in an open-market environment that rewards superior service, top quality, convenience, access, and the right price. These form the grand economic pentagon that fuels the engine of our economy and that has resulted in unmatched innovation. Healthy competition makes you better. It makes the entire system work better, and it gives consumers (patients and referring physicians) a superior product. This model is based entirely on choice. As Harvard professor Regina Herzlinger, PhD, says in her book Consumer-Driven Health Care (McGraw-Hill), our health care system will increasingly be affected by the empowerment of patients to make their own decisions about where they will find the best health care experience. The patient experience is a key driver of an imaging provider’s ability to build brand loyalty and relationships with its various customer groups (physicians, patients, employees, payors, and others). It is this patient experience that will eventually circumvent steerage to providers that these customers view as inferior or inconvenient, or simply overcrowded. The point is this: I have met quite a few outpatient imaging executives distressed by their inability to compete with an entity in their market that is obviously flexing its ability to steer patients in mass quantities. Many of these executives have given up trying to compete and have resigned themselves to the fate of being second-, third-, or fourth-place providers. My response is always consistent. Don’t do it. Don’t give up if you feel that you truly have unique value, if you have superior offerings, if you can do a better job, and if you can create a patient experience second to none. It will take a little time, along with some innovative communications and relationship-building programs, but you can and should compete for the long term. Consumerism is here to stay in health care, and the patients do have choices. Health care consumers of the newest generation know it and will exercise those choices, no matter what their payors try to tell them. Stay focused on the long term and reorient your practice or center to be a place where patients will want to come for their care. Build solid relationships with referral sources; be available, communicative, and responsive. Start chipping away at the steerage blocks at the margins, and you will eventually find that you are capturing market share that you once thought lost to the other guys forever. The ethical foundation of the marketplace will eventually prevail.