Posts Tagged ‘Doctor’

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Pippa Abston, MD – The Terminators: Your Health Insurance Can Still be Canceled

August 21st, 2012

Soon you’ll be able to buy health insurance if you don’t have it—but can you keep it?  Even though the ACA did make it clear that health insurance companies can’t rescind a person’s insurance except for outright fraud, an insurer can still cancel your contract for a variety of reasons.

Rescission is a very specific type of action—it means an insurer cancels your contract retroactively.  Say you are insured but they find out you lied on your application, maybe about your age to get a better rate.  That would still be fraud under the ACA.  They can go back and cancel your contract for the whole time, so that anything they’ve already paid for is now your bill.    But they can’t rescind it for frivolous reasons—the example everyone likes to bring up is rescissions because a person forgot to mention teenage acne, not relevant to their current cancer.

Can they cancel it though, going forward?  Yes.  Nothing I see in the ACA says they can’t cancel your insurance, as long as you are given 30 days notice.  If I’ve missed it, let me know please!  It is long and I’m sure my memory isn’t perfect.

This might be a good time to pull out your insurance booklet (or go online) and see what things can get your policy canceled.  There are a couple on mine I thought you might be interested in.

Here’s one:  “if, after reasonable efforts, a Participating Physician is unable to establish or maintain a satisfactory Physician-patient relationship with a Member, coverage of the Member may be terminated upon fifteen (15) days written notice.  Examples of unsatisfactory physician-patient relationships include, but are not limited to, abusive or disruptive behavior in a physician’s office, repeated refusals by the Member to accept procedures or treatment recommended by a Participating Physician, and a Member’s securing services in a manner that impairs the ability of the Personal Care Provider to coordinate the Member’s care.”

Really?  If a person with my insurance can’t get along with her doc or doesn’t want to do what the doc recommends and my insurer finds out, the policy itself can be cancelled?

I have discharged a small handful of families over the years for that kind of thing—maybe 4 or 5 in 16 years.  If a parent is rude because of stress/ fear, I think it is better to be understanding—but if they curse at or threaten my staff (very very rare), I have to protect my staff.  If I find out they are lying to me about information that could cause me to do the wrong thing for a child, this scares me enough to let them find another doctor they trust enough to be honest with.  But these events are highly uncommon.  I should be able to dismiss those patients without endangering their insurance coverage.

The very idea that a person should lose insurance because of not wanting to do what I recommend for treatment is outrageous!  I have to document when a parent chooses not to follow advice (or forgets to give the asthma medicine, the more common scenario with busy families), partly so I’ll remember and partly for my own protection.   I need to remember later if the medicine didn’t work only because it stayed in the bottle, not because it wasn’t the right thing for the patient, since that can affect my treatment advice in the future.

Practices that take non-vaccinating families often use a detailed signature form documenting the possible risks of that decision (because doctors have been successfully sued by parents who said the doctors didn’t try hard enough to persuade them to do shots, followed by a child’s death from the preventable disease).  I had to do a deposition once in a divorce case, when one parent alleged the other didn’t follow my advice, standard, on limiting junk food and TV time.  I was very plain with the attorney that I tell everyone this and most people don’t listen.  In fact, some insurers require us to document specific preventive advice.  Will that now be a reason to lose insurance coverage?  How can doctors write accurate, useful records without putting our patients at risk?

Here’s another one:  “If a Member fails to pay a required Copayment, Coinsurance or Deductible, coverage may be terminated upon thirty (30) days written notice.”

Someone seeing a doctor or multiple doctors frequently for treatment of a serious illness would be expected to run short of co-pay money at times, especially if the illness caused that person to be unable to work.  Some doctor contracts with insurers say we are required to notify the insurer if a patient doesn’t pay the co-pay.  No time limit is given—what if the patient pays a month late?  90 days late?  Since insurers can’t cancel based on a person’s health status, will we see contract language like this being used for cancellations?  Naturally, an insurer would be unlikely to investigate co-pays by a patient who was inexpensive to them.

We must expect to see ever more creative ways of dropping expensive patients, as we go forward with healthcare reform.  Maybe you think it sounds unlikely, but remember that frivolous rescissions were common in the past.  An insurer that has the nerve to say leaving acne off a form is fraud will do other bad things.  If you get sick and are dropped from your employer policy, I guess you can immediately get one on the Exchange—and when that one drops you, you can get another one.  Each time, you may have to switch doctors and medications based on the insurer’s preferred lists.

You know I have to say it—we could avoid all this policy termination and intimidation by moving quickly towards Improved, Expanded Medicare for All.

Posted with permission from Pippa Abston’s blog.

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Going to the family doctor costs less in Canada

August 15th, 2012

Thirty dollars vs. $100. That’s the difference between the cost of seeing a family doctor in Canada and seeing one in the United States. That $100 is paying for the extra number of people it takes in your average physician’s practice to process the dizzying amount of paperwork required by the health insurance companies. Take out that health insurance middleman, you take out that extra layer of administration, and costs will go down. It’s really that simple.

Sylvia@californiaonecare.org

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Concierge care and retail clinics: two-tiered health care?

August 8th, 2012

Do you feel like a doctor’s visit these days is sometimes akin to being herded like cattle? My mother related to me that her recent visit with her doctor lasted “five minutes.” She may not have been exaggerating. A few minutes is hardly enough time for a physician to thoroughly examine anyone. So some patients are turning to what’s called “concierge care” – paying a doctor an extra annual fee for the privilege of more time and attention. Critics of concierge care worry that if it becomes widespread, it could make access to care more difficult for those who can’t pay extra. But the doctors who provide the service say it’s a way to relieve the burden of seeing so many patients during the day, gives them the opportunity to do a more thorough job for their patients, and helps keep them from losing money in an environment of high costs and low reimbursement rates.

Meanwhile, a shortage of primary care physicians, combined with the expected influx of 30 million people soon to be added to the insurance rolls via the Affordable Care Act, is contributing to the rise of retail medical clinics. Retailers such as CVS Pharmacy and Target are building in-store clinics which employ nurse practitioners or physician assistants to provide simple check-ups and treatments for minor conditions. Critics contend that these retail clinics are inadequate for managing more complex conditions. But the harder it is for people to get a doctor’s appointment, the more people turn to these clinics.

Both “concierge” care and retail health clinics are symptoms of a dysfunctional American health care system where the quality of care is still determined by how much someone can pay. So we are hurtling toward a two-tiered healthcare system, one where the well-to-do can pay extra for more attention and another where people who can’t get a doctor’s appointment at all must turn to the limited offerings of a retail clinic.

These trends show how the United States hasn’t kept up with the rest of the industrialized world with universal healthcare systems in producing enough primary care physicians for its population. According to the Organization for Economic Co-operation and Development, the U.S. has 2.4 physicians per 1,000 people compared with an average of 3.1 per 1,000 for all OECD nations. No wonder those doctors turning to concierge care feel rushed. And no wonder corporations see an opportunity to fill a void.

Medical school tuition in America is way too expensive, forcing many young physicians to eschew primary medicine (or practice in rural and low-income urban areas) in favor of entering the more lucrative specialties. By 2015, the U.S. will be nearly 63,000 doctors short of what’s needed for the population.

“We have a shortage of every kind of doctor, except for plastic surgeons and dermatologists,” said Dr. G. Richard Olds, the dean of the new medical school at the University of California, Riverside, founded in part to address the region’s doctor shortage. “We’ll have a 5,000-physician shortage in 10 years, no matter what anybody does.”

The American Medical Association in the past worked to keep a lid on the number of new doctors because the organization feared a physician glut. So the construction of new medical schools slowed. The AMA’s error in judgment has proven costly for our healthcare system. Another contributor to the physician shortage has been federal spending cuts to training programs for medical graduates. Add to all this an aging baby boom population, an exodus of retiring physicians and a lot of unhappiness within the medical profession itself.

We now have another mess, on top of out-of-control costs and unequal access. Even with the Affordable Care Act in place, many may still not get the care they need, unless they can pay extra. Under the ACA, the Obama administration has pledged to provide funding to train more primary physicians to practice in underserved areas. Yet, more must be done. The cost of medical school – like the cost of college – must come down dramatically. Without the burden of crushing loans, more newly minted doctors can go into primary care. Taking the profit out of health care by establishing a truly universal, publicly-supported system would also help bring bloated specialist salaries back down to earth. If the U.S. had in an earlier time treated health care as an equally shared public good, rather than a commodity, the very idea of having concierge care and corporate health clinics would sound like a bad joke.

Sylvia@californiaonecare.org

 

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Don McCanne, MD: More Aetna abuses, but wait, there’s worse

August 2nd, 2012

Aetna sued over out-of-network pay and referrals

By Alicia Gallegos

American Medical News, July 23, 2012

The California Medical Assn. and more than 50 physicians are suing Aetna over alleged retaliation against doctors who refer patients for out-of-network care.

The medical society and doctors say Aetna is underpaying out-of-network physicians, refusing to authorize some out-of-network services and illegally terminating the contracts of doctors who make such referrals.

The insurer’s practices violate California law and interfere with doctors’ medical decisions, said Long X. Do, CMA legal counsel.

The plaintiffs claim some of Aetna’s insurance policies enable patients to receive out-of-network care. However, Aetna discourages such practices and regularly refuses to pay for them, the suit claims.

Similarly, doctors’ contracts with Aetna do not specifically forbid all out-of-network referrals, the suit said. Yet, when doctors make such referrals, Aetna frequently threatens them with a “rate adjustment” or termination from Aetna’s network, according to the suit.

In a statement, Aetna spokeswoman Anjanette Coplin called the suit baseless and denied the insurer is mistreating physicians.

“Doctors who entice patients to have procedures performed at out-of-network facilities that they own without the patient’s knowledge are putting profits over their patients,” she said. “The wildly inflated bills of these facilities drive up the out-of-pocket costs for unwitting patients and needlessly add to premium costs for everyone.”

The CMA is aware of Aetna’s lawsuits, but said its suit has nothing to do with them. CMA’s claim centers on Aetna’s policies and practices, Do said.

http://www.ama-assn.org/amednews/2012/07/23/prsa0723.htm

And…

Silicon Valley Surgeons Risk ‘Moral Authority’ For 200% Returns

By Peter Waldman

Bloomberg, July 18, 2012

The anesthesiolgists’ ball in December 2010 was already raging when Dr. Thomas Elardo and his wife arrived. It was 11 p.m., and the Opera House in downtown Los Gatos, California, was packed with nurses and doctors dancing to ’80s covers by The Microbes, an all-doctor band. Elardo climbed the stairs to the mezzanine bar and was immediately gladhanded by Bobby Sarnevesht, a local entrepreneur, and orthopedist Samir Sharma, who pulled Elardo aside.

Elardo had known Sharma for years, but the orthopedist had never given him the time of day. That night was different — he had something to show Elardo. At the bar, Sharma flaunted a $960,000 check, Elardo recalls. Sharma said it was for his work as a surgeon and investor in an outpatient surgery center in Los Gatos, operated by Sarnevesht.

“They were saying, ‘This is the kind of money you can make. You’ve gotta come in!” recalls Elardo. “I was speechless.”

Founded by Sarnevesht and his mother, Julia Hashemieh, Bay Area Surgical Management has marshaled decades of doctor rage against insurance carriers into a profitable business.

By rejecting the discounted contracts that participating in-network providers sign with insurers, the surgery centers bill insurance companies at their own out-of-network rates, which are 5 to 35 times as much as the in-network facilities charge, and make a killing.

Knee arthroscopies that cost $3,000 in Aetna Inc. (AET)’s network earn nearly $20,000 in facility fees at Bay Area’s surgery centers, according to Aetna, the Hartford, Connecticut-based health insurer. A bunion repair that costs $3,700 in-network got almost $53,000 for Bay Area Surgical Group, one such center. A disc surgery for lower-back pain, called a laminectomy, costs about $6,000 in network yet reaps nearly $120,000 for Bay Area Surgical.

Fed up, Aetna sued Hashemieh and partners in February, claiming they gouge on rates, pay surgeons excessive compensation for referrals and defraud health plans.

http://www.bloomberg.com/news/2012-07-19/silicon-valley-surgeons-risk-moral-authority-for-200-returns.html

Comment:

By Don McCanne, MD
Although it is always tempting to take on the abuses of private insurers such as Aetna, this time we should look further: the system by which we finance health care in the United States.

Perhaps the most important contribution of the private insurance industry in the past several decades has been the slowing of health care price increases through the process of provider contracting. Of course, public insurers such as Medicare are more effective, though through administered pricing rather than contracting. Nevertheless, health care prices would be even higher had the private insurers not engaged in contracting.

A problem that has never been satisfactorily resolved, in spite of many efforts, is what to do about charges by physicians and facilities that do not have contracts with the insurers – out-of-network providers. In some instances, the insurers pay nothing, except when required by law in certain emergency situations. In other instances, the insurers may pay at lower rates than they do for in-network providers, leaving the high balances as the responsibility of the patients. Often insurers will attempt to negotiate rates after the fact in order to prevent their clients from being stuck with these very high balances.

It is the latter situation that has become a problem. The Bloomberg article above (a very long, ugly story) goes into detail explaining how some entrepreneurial types in the health care delivery system have leveraged out-of-network care into a very lucrative operation. I dare say that Aetna looks like a saintly organization in comparison.

Why should we care? To quote Anderson, Reinhardt and colleagues, “It’s the prices, stupid!” In spite of the limited success of provider contracting, the private insurers have not been capable of adequately controlling price escalation, which is far greater than in all other nations – nations that depend on some sort of government role in establishing fair prices that cover costs and provide fair margins. We all pay more through higher insurance premiums when gougers are rewarded by the private insurers.

Seeing that everyone receives the care that they need, and controlling prices, are the most important functions that the private insurers should be carrying out. Yet they are doing neither competently. The defect is in the design of our health care financing system. The flaws in a system of competing private plans cannot be repaired. The private insurers will never have enough power, and even if they did, how would they use it? And those greedy health care providers who place business interests above professionalism will always be with us.

By replacing the private insurers with our own universal public financing program – an improved Medicare for all – we can include everyone, set prices at their proper level, and shut down the gougers. What are we waiting for?

Re-posted with permission from pnhp.org.

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