Not What The Doctor Ordered
(Page 6 of 6)
But the vast resources and power of the insurance companies allow them to win most fights. In Houston, 5 doctors in a group of 37 filed suit against Aetna in 1993 after being dropped from its plan; a similar suit was filed against Prudential. The Texas medical Association and the Harris County Medical Society joined both suits, the goal of which was to force the insurance companies to institute a fair hearing process and to stop firing doctors without cause. (The appeals process of most companies that claim to provide due process is woefully inadequate.) So far, the plaintiffs have made little progress. Prudential’s attorneys stonewalled to such an extent that those plaintiffs gave up and threw their energies behind the Aetna suit. But that case was thrown out on a jurisdictional technicality—the court passed the buck to the Texas Department o Insurance—and an appeal is pending.
When patients tried to go to bat for their doctors who had been “deselected,” the insurance companies occasionally misled them. Patients of Harold Fields, a Houston family practitioner, who called Aetna asking for the reasons behind his termination were told alternately that he had resigned from the plan or that he had moved out of town, neither of which was true. When the representatives of the Communications Workers of America tried to investigate Prudential’s deselection procedures—which had affected about 2,500 people, including those with pregnancies and serious illnesses—they were initially told that no deselected doctors should have been surprised by their terminations; all had been repeatedly notified that their performance ratings were low. When the CWA produced evidence to the contrary—letters from doctors showing they had never been contacted by the company, letters from doctors who had learned of their firings from their patients—Prudential representatives changed their story. “There wasn’t anything we could identify in any way that was wrong with any way that was wrong with any of the doctors,” says Jeff Bartlett, who then headed the CWA bargaining group.
It seems to be the insurance companies’ belief that a few doctors lost in the shuffle aren’t of much importance, and for their purposes, that’s probably true. “Thirty-seven doctors fired out of two thousand seven hundred isn’t very many,” Joseph Blanford, the Aetna vice president, had said of the mass deselection that led to the physicians’ lawsuit against his company. But thousands of patients were displaced, a fact that seemed to concern Aetna very little. Patients wrote in begging to keep their doctors, with little response—usually a form letter—and to no avail. Aetna isn’t the sole offender, of course. The Texas Medical Association has collected letters of complaint naming almost every insurance company involved in managed care in the state. Asians and Spanish speakers beg to keep the only doctors on plans who speak their languages; elderly couples beg to be saved from long car trips for frequent doctor visits. One of the most poignant letters went to Kaiser Permanente, from a man whose wife would have to give up her job to take him to dialysis. Couldn’t he please be allowed to go to dialysis in Denton, where he lived, rather than in Dallas, forty miles away? But why should the insurance company bother? Indeed, the more difficult care is to acquire, the more the insurance company benefits. If no one goes to the doctor, the company doesn’t have to pay.
If the insurance companies were actually improving—rather than simply changing—the way health care is delivered, maybe the chaos they’ve created could be excused. But many cases resemble that of Peter Benjamin, a highly regarded Pasadena pediatrician dropped from the Aetna plan after eight years—eight years during which Benjamin never heard a word of complaint or praise from Aetna or received a single visit from a company representative. Benjamin’s patients complained to the company and asked for his reinstatement but got nowhere. “They didn’t care at all about the doctor-patient relationship,” says Benjamin. Finally Benjamin learned from Aetna executives that he was being dropped from the plan because he didn’t have enough Aetna patients in his practice: One hundred and fifty families were not enough to make Benjamin worth Aetna’s while. Insurance companies place a premium on corporate loyalty and controlling the largest possible volume of patients. (A primary-care physician may have as many as two-thousand patients.) Of the three Aetna-plan pediatricians in the immediate area, Benjamin guessed that the insurer may have considered his practice the most expensive. Benjamin did lab work in his office instead of sending it out and passed on that cost to his patients. But, he believed, this saved money; having his own lab meant faster results, so he caught illnesses earlier, preventing hospital stays.
Once Benjamin was fired, the other two pediatricians’ practices were thrown into disarray. The physician closest to Benjamin’s office began receiving calls from Benjamin’s former patients, but he was too busy to see them immediately, as Benjamin had. Sometimes they faced a wait of two to three weeks. Naturally, the patients on the Aetna plan complained, so a company representative contacted Benjamin’s colleague and wanted to know who his backup physician was. “Well, it was Dr. Benjamin until you fired him,” he replied. Eventually, Benjamin was reinstated in the plan. “It would appear that a boo-boo was made,” he says. “If a company is in a profit mode, you try to cut costs, and I can commiserate with that. But really and truly, how did they save money by knocking me out and giving my patients to other doctors?”
Since rejoining the plan last April, Benjamin has tried to have a more active relationship with the company. When he received a new progress report, he called to ask a company representative to come out and interpret it for him. It was months before help arrived. Shortly after he filled out his new contract, he received a letter. One question had asked if he had ever been fired from a plan before, and he answered yes, by Aetna. He got a letter back from Aetna asking him to explain the details. The company that had also been so quick to notify Benjamin’s patients of his deselection shrugged its shoulders when he asked it to send out notices of his reinstatement; Benjamin was told the list of his patients’ names had been lost. “This is idiocy,” he says. “It didn’t serve me or my patients well, and it didn’t serve Aetna well.”
Out of Business
BY LATE FALL, DR. B.’S anger had turned to grief. As the date of his firing drew near, he considered suing, but his friends advised him against fighting back. “They want you out,” said a friend who had once worked as a managed-care administrator. Beneficent had overcommitted, she explained. It already had too many doctors on its plan; Dr. B. was another doctor whose patient load didn’t generate enough income for Beneficent, and besides, he didn’t play the game. “Even if they let you back in for a while,” she added, “they’ll find another way to get rid of you later.”
The fight had gone out of him anyway. Beneficent was a large corporation; the pride he took in the small practice he had built over decades was utterly lost on the big company. “I cannot go and beg to see my own patients,” he said at the time. And something else had come up: He had been offered a spot in a group practice that would help him absorb the financial loss of Beneficent’s patients. “The more anonymity I can maintain…” he began, his voice trailing off.
There are two things that Texas physicians and insurance companies seem able to agree on. The first is that our state is in its turbulent early adolescence as far as managed care is concerned. The second is that we will all grow old with managed care. The only fight left to fight—for doctors and their patients—is to reform that system. Two upcoming legislative initiatives could help. The first is what is known as an “any willing provider” law, which prevents insurance companies from arbitrarily closing plan memberships to qualified doctors. The Patient Protection Act goes further, calling for an end to “termination without cause” contract clauses and requiring due process appeal procedures for doctors dropped from plans. The adoption of both would reduce the power of insurance companies to dictate health care. Patients can pressure their employers—who, after all, are the power behind the insurance companies—to have a voice in the plans that are selected. The most-optimistic physicians believe that as competition increases insurance companies will be forced to deliver a higher quality product. Doctor-run HMOS, like Scott and White Health Plan in Temple, for instance are already developing a reputation for high-quality, low-cost care. Competition, insurance companies might learn, is good for everyone.
Sometimes, goes an old adage, things that appear to be 180 degrees apart are actually identical. No one really knows whether managed care, having evolved into the polar opposite of the indemnity system, will prove to be an improvement upon it. No one really knows whether managed care actually saves money or just shifts it from doctors’ pockets to the insurance companies’. As has often been noted, the CEOs of such plans draw multimillion-dollar salaries and bonuses. (Leonard Abramson, the head of U.S. Healthcare, reportedly made about $10 million in salary and stock options in 1993.) Meanwhile, the profits of drug companies continue to soar and the giant for-profit hospital chains continue to expand unchecked, though reform of both could have an enormous effect on the cost of care. So, too, could tort reform, which will be before the state legislature this session.
And what will become of the doctors? Is it socially beneficial that doctors who treat the very ill are being driven out of business? Who benefits when medical innovation is deemed a luxury we can no longer afford? As the institutional memory of older physicians—and older patients—fades from the present system, so will the relevancy of such question. The next generation of patients and professional will know only one norm, and it will be managed care.
Dr. B.’s last patient of the day, a man on the Beneficent plan, was leaving. He had come in with his wife and child, a dark-haired little girl who had darted about the office while her father was being examined. “I counseled them when they got married. I was there within hours after their little girl was born,” Dr. B. said as they left, closing the door behind them. “Now they can’t come anymore.”
