Why did my doctor leave my managed care network? The problem with managed care…
Since the 1990’s, the managed care networks are something we in the United States have been forced to live with. Many doctors joined these networks because access to patients became synonymous with the networks. Employers embraced these networks because they saved costs, or at least, this was the promise made to all of us. Patients learned to rely on these networks because medical costs out of the network were often egregious, while in network, they appeared to be reasonable, or at least this is what the insurance industry wanted us to believe.
During the last decade, the cost of insuring ourselves continued to rise, which left many of us wondering how and why, especially since we were finding ourselves pushed from network to network, as we were priced out of the previous plan, often the one with a better choice of health care providers. In other words, the price has risen far greater than it seemed on the surface. As this continued year after year in the past decade, we also noticed the newer plans had us paying a higher share of the visit (sometimes $50, or more for a doctor visit, sometimes thousands if we had a medical procedure performed). Many of us who never changed how we used healthcare did not understand how the cost of care that was managed by the insurance industry could continue to skyrocket, when managed care was supposed to solve this problem. Managed care was a broken promise since it made changes in the system that in many ways actually increased the cost of care, rather than decreasing it.
The part you never saw was the constant squeezing of the primary healthcare and specialist provider financially as the insurance industry forced them into the 10 minute visit model, and no longer paid them for visiting you if you were in the hospital. This created the need to hospitalists who regularly do the visit for your doctor, reporting on your progress at a higher cost than if your doctor woke up early and did the visit. This made your relationship less personal as the doctor no longer took the time to help you figure out your problem because they could no longer afford to. More than 10 minutes, and less than 6 patients an hour caused many established practices to hurt financially, which is why they will often refer you out to specialists. Therein lies the problem. The specialists look at a small portion of you even though your problems are likely much bigger. They are paid more, and after they look at their small area, rather than the systemic approach your primary doctor would have used cost much more because you are now in the system and go from doctor to doctor to….; well, you get the idea.
This is far more costly, and statistically has created a system where people end up with expensive procedures they may have been able to avoid if their primary doctor would have been paid to spend the hour if needed. This is especially true for Geriatricians who need to spend the time with their elderly patients and are penalized for doing so. This parallels the changes the airlines made with deregulation in the 1970’s, where they created the hub and spoke system which is why many of us cannot get direct flights. Fuel was relatively cheap in the 1970’s so hub and spoke was quite affordable. The reality is that flying to Chicago from New Orleans and then secondarily taking a second flight to Newark is less desirable than flying from New Orleans to Newark direct; however the airline will charge more for a direct flight even though flying the first way requires more fuel, two separate flights and more time. In other words, the cost to do this is much higher, but seems to be preferred because it is the established way of doing business. In many ways we are all paying for it with higher fares and smaller seats as we cattle from place to place. The modern healthcare system is run in a similar fashion except instead of too many flights, there are too many tests, too many doctor visits and nobody is looking at the system creating your symptom, other than this expensive and wasteful haphazard way of stumbling through the diagnostic nightmare that often results in either negative tests (often because of the lack of musculoskeletal evaluation knowledge) or expensive drugs and treatments that may or may not improve your situation.
Many doctors who have had their fees reduced by insurance carriers and modified their offices to work with less reimbursement are again seeing reductions, although because of inflation and a higher cost of doing business, most cannot afford to work for any less and will likely just drop the plan since they can only lose money on a patient visit. Our office recently has decided to leave Aetna for this reason (huge cuts and caps in our already reduced reimbursement levels), and after speaking with many doctors we work with, many of them are doing the same.
Market forces, the terms used to explain this are really not market at all. Insurance companies dictate their next move to providers and as a provider, you either tolerate it or move on, without any discussion or negotiation. If on the other hand, the insurance companies move to further discount back fires, and doctors begin to leave in droves, then the insurer may come to the table to discuss things with their former doctors to woo them back to the table. This happened years ago when Aetna absorbed US Healthcare, adopted their doctor unfriendly policies and watched their investment decrease in value as doctors left. Ultimately, a new medical director began to woo them back with a better attitude and better levels of reimbursement at least for a while.
As the patient, you feel betrayed and inconvenienced, however, it is another reason why we as a country should have a single payer system. The simplicity of a Medicare for all would cut administrative costs for doctors, and greatly enlarge the pool of available doctors, eliminating the current model of different entities, with different fee schedules rules and drug formularies and would also help inner city hospitals since Medicaid reimbursements is what has placed them in financial peril. Under the current model, the money is collected by the insurance company who manages risk. The current model of arcane rules, continued reductions for providers, and the modifications to the way we practice today with technology leading the way as primary care doctors of all types are underpaid, while specialists who do procedures own surgicenters to get the money they require to stay financially healthy is crazy. This is why facility fees are rediculous for the hour (doctor gets $600, anasthesia $400, facility $1300). This is further exacerbated by the everyday denial of clean insurance claims, denials of certification, and other games played by the insurer, which increases your doctors cost of doing business because requiring more people to run their small offices.
Most physicians will leave when they believe that out of network will serve their patient base and their own ability to practice better. They seek freedom from more payment reductions (or in the doctors eyes, abuses of the carrier) while they expect more out of a broken system which the healthcare carriers have lost control of. The system is in need of change, which is the way to lower costs markedly.
Where does this leave you, the patient
Insurance may be going away permanently in the way you previously used it. More employers are becoming self-insured or are joining self-insured pools. You may not know the difference because the card says Aetna, Horizon or Qualcare, however these plans are involved in the growing acceptance of third party administration. These plans are not under the same state rules that protected you previously, but are under the national Erisa guidelines. You will still have networks, but the employers exert more control under the names you have known about who used to be the insurer, but now are instead just processing the fees and managing the network or leasing their network of providers.
What should you do if your doctor leaves the network
- Find out what is covered out of the network. Many HMO and EPO plans are have no out of network benefits. Many PPO or point of service plans have a deductible for the year and a copayment, which you may find out are affordable to you. Your doctor’s relationship, since they know you and visa versa is a relationship that has taken time to develop.
- If you have out of network benefits, the cost of chiropractic care which has always been priced affordably still is. Unlike many medical tests, the chiropractic visit is still relatively inexpensive.
- You may not notice any difference if you have a plan with a deductible. Many plans that had a low deductible do not change when your doctor went out of network. In many cases, you will pay slightly more for care because the in network rates are artificially low and you may notice less interference with your care as you would in network with care caps and certification requirements. Many primary care providers have tried to keep their fees reasonable and are seeing a growing segment of their patients stay with them even if they leave the network.
- You maintain the relationship with someone you trust to do the right thing for you. Sometimes, it is worth it to stay with a provider who truly cares about you and has earned your trust. This is especially true with chiropractors and primary care doctors since most of them value their relationships and maintain these relationships not only with their current patients but often with entire families.
- Discuss any concerns with your doctor. Many doctors will be candid about why they are leaving (many will tell you why) and have good reasons for doing so. Just as you would leave any employer who did not value your work and wish to cut the amount you are worth even as your cost of living increases, doctors will likely do the same for the same reasons.
- Consider joining a plan the doctor continues to work with. This will give you the same in network benefit you had before. Some larger employers give their employees a choice of which plan they can be a part of. Take advantage of this if you can.