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Insurers' Arbitrary Discrimination Affected My Patients, Family & Career
Don Shuwarger, M.D., F.A.C.O.G. , OBGYN.net Editorial Advisor
Copyright 1996
Bedford Women's Center
1700-D Whitfield Dr.
Bedford, VA 24523-1401
+1-540-586-6818
email: obdoc@inmind.com
Online CV: http://www.inmind.com/people/obdoc/dscv.htmlClear Lake is a bedroom community halfway between Houston and Galveston. The community is home to the Johnson Space Center of the National Aeronautics and Space Administration (NASA). Also located in Clear Lake are many subcontractors to NASA , the University of Houston-Clear Lake, and a few medium and many small businesses. It is a tranquil neighborhood with a low crime rate, high educational level and access to varied recreational opportunities. It seemed, eleven years ago, to be a perfect place to settle and set up practice.
My solo-practice Ob/Gyn office grew quickly and I became involved in the community. As chair of the Clear Lake Area Chamber of Commerce task force on health care, we developed community outreach programs and health fairs. I gave a seminar, with others, at the Johnson Space Center on the space technology "spin-offs" benefiting medical care and I led numerous other seminars on women's health care topics. This community was everything for which I had hoped and was very accepting of me.
Managed care was something that, while always present in the community, was not a very significant factor in my practice. Most of the NASA subcontractors, nearby oil-related industries and small businesses provided their employees with a choice of insurance programs. These ranged from traditional indemnity insurance to preferred provider organizations (PPO) to health maintenance organizations (HMO). While some larger group practices depended heavily on managed care programs, my solo-practice flourished without the need for participation in the alphabet soup of managed care. It's not that I shunned accept managed care, but rather there was no need to participate and the office couldn't handle the additional patient volume or administrative load.
All that changed abruptly. In October, 1993 it was announced that numerous NASA subcontractors were going to contract with the same insurer for HMO and PPO products. A traditional indemnity policy was offered but was priced so prohibitively that few if any families could afford it. Many other medium size employers and oil industry firms followed their lead. Within a few weeks, there were going to be drastic changes in my patients' access to health care. Patients called daily and asked us to participate in their plans.
It was apparent that if my patient's continuity of care and freedom of choice in health care provider was to be preserved, I would need to participate with the major managed care plans. Calls were made to the provider relations offices of Prudential, The Travelers, MetLife, SANUS, Blue Cross/Blue Shield and Aetna. My staff asked for applications to be a provider in their managed care plans. We figured that during the application period we would work hard at preparing our office for the administrative responsibilities and changes that would come. We had a lot to learn in a short time.
Our first surprise came when we received a terse letter from The Travelers . Thank you for your interest, it said, but they were unable to offer me an application. Then the same from Prudential. Yet another from MetLife. The final ones were crushing. Every HMO and PPO contacted refused to send an application. Most stated that they had enough practitioners of my specialty in my geographic region. Soon, over three thousand patients were to find themselves a new gynecologist because their managed care plan was not willing to send me an application.
Patients did not understand this. Many said they were told by the insurer and their company that they could ask their doctor to join or ask the company to contact their doctor to see if he/she was interested in joining their managed care plan. Many patients told me that the insurer told them at company meetings that the managed care plan only accepted physicians who were highly qualified. The impression left with my patients was that I must be less than qualified.
Confused, bewildered, hurt and scared, I turned to the Texas Medical Association (TMA) for information. Their general counsel advised me that state law requires PPO plans to provide physicians with a fair, reasonable and equivalent opportunity to participate. However, many of these plans evade state law by claiming protection under federal ERISA preemption . He wrote letters to four insurers for me, but received only a verbal response from Aetna. I wrote repeatedly to the Texas Department of Insurance and received no reply.
Another flurry of calls to the TMA resulted in the suggestion that I contact as many patients as possible who have been affected by this situation. It was recommended that patients be asked to contact both their insurers and the Texas Department of Insurance and register their complaints. So far, there had been no action by the Insurance Department. Aetna did suggest that I could appeal their refusal to provide me an application. Such an appeal was filed, but it was laughable. How could I begin to provide an appeal of an arbitrary decision not based on anything within my control, such as training, experience, board certification and the like?
The effects and implications of these insurance company exclusions were profound for my patients, staff, and family. Literally thousands of patients had to abruptly change physicians, often in the middle of treatment or pregnancy care. The volume of medical records copying and mailing bogged down the staff and destroyed moral. Patients cried about the disruption in their care and being forced to change physicians against their will. Oh sure, they could continue to see me, but they had a one thousand dollar deductible and then only sixty percent coverage afterwards. When this is compared to no deductible and a ten dollar per visit co-payment, there is really no reasonably affordable option to see a physician out of their plan. My family and I were constantly asked why I don't participate in these various plans. People are polite, but underneath their question is the unspoken doubt of my qualification. As a board certified obstetrician and gynecologist with a strong record of quality patient care and an absence of any disciplinary or regulatory actions, I am highly qualified for any physician network. But patients and friends have openly and quietly wondered if this is so.
Access to quality health care and freedom of choice of physician have been identified as national priorities . When six insurance companies who are responsible for thousands of patients in a community refuse to even send an application to a long-term established community physician, one must ask if this is in concert with the best interests of the patients. Is this behavior corporate bullying of private practice physicians? Are the insurance companies arriving at this policy independently or by coordinated design? Few would question the reasonableness of an insurer including in their panel only physicians who have met certain quality standards. But not to send an application is an arbitrary exclusion, disrupts patient care, removes patient's freedom of choice and restricts access to quality health care.
There are other similar situations. In Texas, some physicians have been arbitrarily removed from physician networks. This process has been dubbed "deselection". This activity is to be deplored for the same reasons, as well as numerous others related to due process and other legal issues. The TMA is currently challenging the "deselection" of physicians . Both deselection and arbitrary exclusion from application are insurance company techniques that serve only their interests. These actions do nothing to improve quality of care, access to care, freedom of choice of physician or maintenance of the physician-patient relationship.
State insurance regulators, physicians, patients, employers and legislators need to take notice of this activity by insurance companies. We all must work to keep those aspects of traditional medical care intact that best serve patients. When insurers refuse an application or deselects arbitrarily they are not promoting quality. We, as a nation, are struggling with transitions in medical care delivery, health care insurance, universal access to care and freedom of choice. Let us loudly denounce insurance company practices that are contrary to these objectives.
Physicians who are aware of insurance company practices that adversely impact patients, access to medical care or freedom of choice of physician have an obligation to work to correct the situation. The most useful way to address these concerns is through a multipronged approach. Give patients information regarding what the state laws require of their insurer. Patients should be encouraged to register their personal complaints with both their state's Department of Insurance and the insurance company. Physicians can also write such letters on behalf of their patients. Most importantly, physicians who have personally experienced such insurance company tactics must do four things.
First, the physician should take all steps to let patients, staff and colleagues know that such refusal of application by an insurer is taking place. By acknowledging this, the physician takes a proactive approach to preserving reputation. It is important everyone know this is an arbitrary action by the insurer and that they have not evaluated the physician's credentials or professional reputation.
Second, the local medical society should be notified. Because of the representation the local society has at the state level, it is helpful for them to be aware of what is taking place in their area. Occasionally, the local medical society will contact employers who can influence insurers. It is also important for the local medical society, and any physician referral service they may operate, to be aware of the situation when callers inquire regarding the physician's credentials and reputation.
Third, the and its general counsel should be advised of this situation in every case. As the single representative body for physicians in the state, they have a responsibility and obligation to help address these concerns. The state Medical Association advocates for both physician and patient when it works to correct this type of discrimination and exclusion.
Lastly, and perhaps most important, physicians who are the victims of this type of arbitrary discrimination and exclusionary policies need to network together. Each separate physician can feel isolated, persecuted and fearful. By sharing experiences with others who have been similarly affected, the sense of loneliness will abate. Also, by talking together we can learn if others have been successful in reversing this problem and what approaches they have used.
As for my family and me, we decided that this crisis in my practice was all we needed to make the final decision to relocate to a rural community. For a couple of years we discussed the pipe dream of life in a small town. We looked forward to less crime, drugs, congestion, pollution and stress. We were lucky to find everything we wanted in a rural Virginia community. But, alas, that is a whole other story.
