A woman in Buffalo, NY, a nurse who works per diem with a primary care doctor, loses her insurance. She’s on medication for a chronic disease, and the medication runs out. So, she calls her doctor to schedule an appointment. But her doctor won’t see her. You don’t have insurance, she is told. Okay, she says, what if I pay cash? That won’t help, she is told. You need insurance for us to schedule an appointment.
At about the same time, I heard a creditable story about a patient with insurance in Orlando, Florida, who needed to see a gastroenterologist and called two different healthcare systems to schedule an appointment. Both turned her down because she didn’t have “the right” insurance.
What’s happening here? In the bad old days, orthopedists used to refuse to see anybody with Medicaid – they’d transfer all those requests to hospital-run orthopedic clinics run by orthopedic residents, and patients might sometimes get appointments in six months for things like fractures (which need attention in more like 6 hours but can sometimes wait a day or two.) And smart primary care clinicians figured out that the way around that was to send everyone with a fracture to the emergency department, which was part of why the emergency department got so overused and had such long waits.
To some (but not to me), the behavior of those orthopedists was defensible. They’d say Medicaid didn’t pay them well, and certainly not as much as private insurance and Medicare. That was true, as far as it went: Medicaid often didn’t and doesn’t pay physicians enough to cover the cost of seeing those patients, and billing Medicaid has always been a nightmare.
(Please remember that the residency of every physician practicing in the US was paid for by public funds, supporting the bulk of the cost of most medical schools. So in my view, every physician has an ethical obligation to care for anyone who seeks care within the bounds of propriety and reasonableness).
But this behavior of physicians refusing to see patients, even if they have insurance or can afford to pay those physicians’ charges, is new.
I asked colleagues if anyone else had heard about this behavior, or if it even has a name. (Setting up barriers to entry, so only profitable patients are enrolled in health insurance for example, is called ‘cherry picking’ – and was exemplified by insurance companies that had offices on the second or third floor of a walk-up building, so only healthy people could climb the stairs and enroll.) Only one of my colleagues replied and the name they gave for this phenomenon can’t be printed in a family news outlet, so everything that comes next is me guessing, but it is guessing based on long experience.
I think hospital systems, which now own the bulk of physician practices, are using their physician networks to develop market power and thereby compel employers to choose their insurance companies and the rest of their hospital networks. There are now lots of employers who self-insure and who don’t buy traditional health insurance for their employees because it costs too much. Those employers have learned to manage their employees’ health care themselves, and in the process save themselves and their employees money. They often do that by making sure employees have primary care doctors; by choosing the most cost-effective hospitals and specialists, and by creating incentives to keep their employees out of emergency departments, which are overused and expensive. The money these employers save comes right out of the pockets of the hospital systems, as those employers reduce emergency department and hospital overutilization. Want access to our doctors? The hospital systems are saying back.“ Then use our only insurance companies or insurance companies we have deals with, the ones that don’t reduce emergency room and hospital utilization. Sure it will cost you more. But what good is health insurance without doctors and hospitals? And we now own the doctors because we bought them. “ Which is a little like owning both Broadway and Park Place in the good old game of… Monopoly!
And this is about not market power. This is people’s health and lives that are being bought and sold. That’s extortion. It is doable because those hospital systems bought up physician practices (often using capital from private equity, which will be the subject of next month’s column).
Once upon a time, when doctoring was about serving communities, physicians would see anyone who wanted to see them within the bounds of reasonability. But now corporations practice medicine or at least own the practices of those who do, and they have no ethical obligations to patients or their communities. Their only obligation is to create profit for shareholders. So they get to do what they want – see who they want, and charge what they want, as long as the market can bear their charges. So we get this kind of craziness – people who were educated and trained with public money, working for corporations with no public accountability whatsoever.
Once upon a time, it was “get sick and have no health insurance – good luck with that.” Now it’s “get sick and have the wrong kind of health insurance or want to use health care intelligently so it stays a little less expensive, well, good luck with that as well.”
Once upon a time, medicine was an honorable profession where people trained for years so they could work in their communities to care for the sick, to listen, to reduce suffering, and to help people get back on their feet as soon as possible. That we have let corporate money and power undermine the integrity of medicine as a profession is plenty crazy. That we don’t use our regulatory power to enforce the public’s interest in health care and secure the common good, well, that’s more crazy yet.
(Actually, the bad old days are apparently still here. I called a large university-associated orthopedic group just to see what they were doing about caring for Medicaid patients, and after spending 11 minutes and 38 seconds on hold, waiting for the privilege of speaking to an “appointment counselor,” I learned that everyone with Medicaid still sends to those hospital clinics, and also that those people will see the same doctors as they would see in their “private offices” which usually isn’t true. Those doctors are likely the attending physicians of record for patients with Medicaid. But those patients are usually seen only by resident physicians, evidence of a very unfortunate two-tier medical system that still exists in Rhode Island today, about which we should all be ashamed.)