When Health Systems and Insurance Companies Go To War
The story was on the front page of our local paper. For the second time this year, a regional health care titan, controlling the majority of practices in our area, has ended a contract with an insurance carrier. I saw the headline and suppressed a wave of nausea and anxiety. Here we go again! First, it was Cigna, lasting half a year, and now it is Aetna.
What happens when a major regional medical system which controls most of the hospital beds and area doctors stops participating with an insurance company?
Short answer: For the patient, their family and the few remaining doctors who try to provide care, usually without insurance reimbursement, it is worse than a nightmare. At least you can wake up from a nightmare. In this case, someone may just wake up dead!Is there abandonment involved? Absolutely. No one at any of the non-participating facilities bothers to check if there is patient instability present. There is no effort to offer options. The patients just get a phone call: “We are cancelling your appointment because we are no longer in your insurance.”For the rare doctors who refuse to abandon their patients, it is a catastrophe. It is also a bit of a malpractice mine field.
You lose all of the involved specialists: Cardiology, Nephrology, ENT, General Surgery, Neurology, Gastroenterology, etc. They vanish. They stop seeing your complex patients. You are now practicing outside of your comfort zone.
Thanks to severe doctor shortages in virtually all fields, you cannot simply transfer patient care to the nearest regional specialist system 50+ miles away. In the rare instance you can get them such care, it will not be timely.
Communication about the details is totally absent because no one understands the implications of going out of network. Most of the involved practices simply terminate appointments. Those that do not reflexively cancel appointments and procedures may ominously warn the patient they are going out of network. How much out of pocket? Are we talking $500, $50,000, more? Nobody knows and nobody will commit. When patients are faced with bankrupting bills, they may let their unaddressed serious medical issues fester for a while until it is too late. No one at any level even knows enough to sit down with patients to explain. No one understands what it all means. No one! No doctors, hospitals, facilities or insurance companies have any comprehension of the final bills which may result.
We did this for an entire half year with Cigna and it was terrible. We saw our Cigna patients who desperately needed care because we believed we risked abandonment otherwise. While patients will try to avoid paying the high rates of specialists, they find paying a primary care doctor is doable. We were the last option for them. It was not good. For practical purposes, most specialists simply ceased to exist locally for these patients. Even as we tried to get them care in Richmond or Northern Virginia, many chose to wait for the two systems to make an agreement, which was not at all a timely event. Care suffered. Did people die unnecessarily? It is possible.
Our system is broken. This should not be happening. This has become a war, complete with casualties and deaths, the sort of thing we are supposed to prevent when talking about “healthcare.”
Ummmmmm, When I started in a surgical residency in 1982, it was said there was going to be an “oversupply” of doctors that the system wouldn’t be able to handle. I was like, “Oh shoot, I went into the wrong profession.”
Little did I know when I got out of residency, I was worked rigorously and didn’t have to worry about “patient supply”. I did bail/get kicked out from surgery and a urology residency and settled in FP in a semi rural area and had a good life after completing an FP residency and passing said boards. Was easy for me after all the crap I went through. The extra training really benefited me in the boondocks.
Now the ITB’s (ivory tower bastids) are screaming for the production of more doctors. I can only say, “What goes round, goes round! Period.”
Only thing is, when I was competing to get into med school, every straight “A” Biology major was applying to them and math, chem and bio-chem folks/majors, who took a more rigorous course work (danged calculus!) had a harder time keeping the GPA’s up. That was except for a few who were straight “A” in the more rigorous sciences. They got letters of acceptance from every med school they applied to. Ummmm back then, biology majors had it easier. Just rote memorization. None of the analytical stuff one had to tune their mind to for advanced calculus.
Isaac Newton must have been “touched in the head” to come up with this stuff but it changed the world.
The rest of us had to hope for a low number on the waiting list of a state med school.
Was lucky I got in. I think my number was “69” and they told me not to worry as they go out to number “90” and greater for the potential students on the waiting list. End of June when I found out the summer before classes started.
Reason #649 why physicians shouldn’t work for large corporations.
It started 30 years ago with HMO. Some of us saw the problems early but were ignored. For example try being a plastic surgeon and having the patient in an HMO demand a plastic surgeon for their little Suzy 1 cm laceration.
You leave your family, spend 2 hours, and the HMO sends you a payment of …$60. For the ER visit, repair, and followup. The hospital says you are not necessary and dont pay for call. The patient, now that they have treatment, states you have to accept my insurance. Everyone is happy except the Dr.
Try refusing and the ER doctor threatens with EMTALA. The patient family is a CEO who makes 10 million a year, flys private jets and demands such treatment, but you are a slave getting $60. The nurses called in get more and dont have 300,000 in overhead. Everyone gets mad at you if you try to refuse. Nurse practitioners get added to the ER and ASK patients if they would PREFER a plastic surgeon, even the drunks with Medicaid HMOs.
If you drop out you dont get any elective referrals. The University doesnt care because they negotiate 3x Medicare rates. A few dishonest plastic surgeons in big cities provide this care out of network, and bill $50,000 which is obscene.
It is beyond broken when the price for the service varies by a factor of 1000.