1. Negotiating with Insurers Game Theory and the The Philosophy of Purchasers and Suppliers

2. Accepting or Declining Discounts with Insurers Consider the following scenario where 2 consultants each undertake 50 cases per annum The total market for insured cases is 100 cases

3. The Start Consultant A Cases p.a. 50 Fee per case £1000 Income £50,000Income £50,000 Consultant B Cases p.a. 50 Fee per case £1000 Income £50,000Income £50,000

4. Insurer offers more cases to Consultant A if they reduce fees by 10%; the total market is the same at 100 cases Consultant A Cases p.a. 56 Fee per case £900 Income £50,400Income £50,400 Consultant B Cases p.a. 44 Fee per case £1000 Income £44,000Income £44,000

5. This means that in Year 1 Consultant A has to do 12% more work and must treat 6 more cases to maintain the same income If the insurer fails to actually send the 6 extra cases Consultant A will see his income drop In this deal consultant A bears all the risk

6. In the next year let us assume that The market has not grown (and there is no evidence to suggest that these fee reductions will be passed on in lower premiums and more subscribers) The insurer has in fact now managed to redirected 20 cases from consultant B to consultant A

7. The new situation with a total market the same at 100 cases is Consultant A Cases p.a. 70 Fee per case £900 Income £63,000Income £63,000 Consultant B Cases p.a. 30 Fee per case £1000 Income £30,000Income £30,000

8. Consultant B is now panicking so The insurer offers to include consultant B in the managed care scheme if he lowers his fees by 10% The insurer then stops redirecting patients and restores the equilibrium

9. The new situation in Year 3 with a total market the same at 100 cases is Consultant A Cases p.a. 50 Fee per case £900 Income £45,000Income £45,000 Consultant B Cases p.a. 50 Fee per case £900 Income £45,000Income £45,000

10. Thus the situation in Year 3 is Both consultants are back treating the same volume of cases Both consultants are earning 10% less than at the start

11. Now the insurer returns to Consultant A requesting a 10% fee cut for more work Consultant A Cases p.a. 56 Fee per case £810 Income £45,360Income £45,360 Consultant B Cases p.a. 44 Fee per case £900 Income £39,600Income £39,600

12. The process restarts and is always a downward pressure Consultant A has to undertake 12% more work and treat 6 more cases to maintain about the same lowered income as the previous year Total income is down for both consultants The redirection and ongoing downward spiral continues……………..

13. The end result of the discounted and agreed fees The patient is excluded from the equation and the consultant/patient contract has been broken This is now being applied on a grand scale by certain major insurers It is a step wise reduction in income for ALL consultants No overall growth in insured referrals

14. This is the end result of discounted and agreed fees Most importantly this means Restriction of Patient Choice