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It's already the start of another holiday season. We hope it's a merry time for everyone.

Happy Thanksgiving!

Americans were promised that if they liked their health insurance plan, they could keep their existing plan -- until they couldn't. (Mine, for example, was cancelled, and California has opted to not allow insurance companies to renew existing policies that do not comply with the Affordable Care Act standards.) Americans were also promised that if they like their doctor, they wouldn't have to change. It turns out that that might be changing as well.

Kaiser Health News reports that doctors are being offered lower rates for their services when they treat patients who are insured by a plan that is offered on a state exchange. What is particularly surprising is that doctors are apparently being offered rates below Medicare. This is concerning because over the past few years, media has reported on doctors opting out of Medicare precisely because of the economics. While the original assurance of being able to keep one's doctor may have been well-intended, the actual economics might force a different reality on patients.

Because of the lower rates, some doctors have been opting out of the new plans that are offered by the exchange. A problem that is surfacing is that insurance companies don't present the most up-to-date listings, and so consumers don't have a great way of checking their doctor's network information online. Another unfortunate hitch.

Often, health care purchasing in America is not tied to quality. That's in large part due to the lack of widely accepted quality metrics. As a result, patients often select their care based on personal recommendations or other proxies for quality (e.g. perhaps they feel that academic medical centers are better quality). Hospitals themselves have a difficult time differentiating themselves on quality. Even if they wanted to publicly post their quality metrics, other hospitals in the area might not have an incentive to follow suit since they can easily dispute the usefulness of such metrics. As a result, hospitals will advertise on things like having the latest equipment which might be perceived as a proxy for quality, but is actually a poor substitute.

Over the last couple of decades, a variety of pay-for-performance schemes have been gaining momentum. Recently, Medicare has started to roll out financial incentives based on their quality metrics. Currently, however, the actual extent of the incentives seem pretty limited: only one hospital will lose more than 1 percent of its reimbursements. The stakes get bigger next year, and it will be interesting to see if the numbers get big enough for hospitals to change their behavior.

There is conventional wisdom all around us. Some times, such wisdom is held in such regard that no one really challenges it. Other times, people take a closer look and find some surprising results. Having worked on a patient health record before, I have personally heard about doctors' concerns about what might happen if patients actually saw their doctors' notes (gasp). While patients are generally entitled to a copy of their medical records under HIPAA, I've met doctors and administrators who have been less than thrilled about making that process easy.

Clinicians at Beth Israel Deaconess Medical Center and Harvard Medical School ran a pilot program where primary care doctors actively shared their notes with their patients. The result? "Perhaps the most telling statistics of all: Not one of the 105 primary care doctors elected to stop providing access to notes after the experimental period ended." This is a remarkable departure from the general sentiment that I encountered earlier.

What might be next? Maybe the idea that doctors will never post prices? How about their publicly posting outcomes-based quality data? The path might be long, but we can still hope.

The Wall Street Journal ran an interesting article on how some doctors are surprised to be inaccurately listed as accepting certain insurance plans. The author of the article wrote, "Exchange officials blame the insurance industry, where inaccurate and out-of-date provider lists are nothing new." Interestingly, we've encountered something similar. We found a doctor listed on an insurance company's website, and we thought it odd since we hadn't heard of that insurer in this area. We proceeded to call the doctor's office and the person who answered the phone said that he hadn't heard of that insurance company. This can have implications for those who might be switching health plans: such patients might be sorely disappointed to find out that a doctor they were expecting to accept their new insurance doesn't actually accept it. While industry insiders might know about the long-running inaccuracies of insurance databases, the general public might not.

What's particularly interesting about that article is how even the doctors' specialty information was listed incorrectly -- to the extent that CoveredCalifornia removed such information from their website. Needless to say, looking for a new doctor is much harder without the specialty information. Hopefully, the databases that insurance companies have will become more accurate on both counts.

For those who are curious, we generally figure out which doctors accept which insurance plans by checking with the website of the medical group. We believe this is more accurate (the provider's office is largely the one that would have to handle patient outrage of being billed extra for their being "out-of-network" despite being told otherwise). However, the downside is that not all provider directories will list insurance information. We expect that the situation will improve over time, especially as more information becomes available online.