A Doctor’s Perspective On Obamacare Plans

obamacareBy Jeffrey Cohen, WNPR

On a recent afternoon at his office in Hartford, Conn., Dr. Doug Gerard examines a patient complaining of joint pain. Gerard, an internist, checks her out, asks her a few questions about her symptoms and then orders a few tests before sending her on her way.

For a typical quick visit like this, Gerard could get reimbursed $100 or more from a private insurer. For the same visit, Medicare pays less — about $80. And now, with the new private plans under the Affordable Care Act, Gerard says he would get something in between, but closer to the lower Medicare rates.

That’s not something he’s willing to accept.

“I cannot accept a plan [in which] potentially commercial-type reimbursement rates were now going to be reimbursed at Medicare rates,” Gerard says. “You have to maintain a certain mix in private practice between the low reimbursers and the high reimbursers to be able to keep the lights on.”

Three insurers offered plans on Connecticut’s ACA marketplace in 2014and Gerard is only accepting one. He won’t say which, but he will say it pays the highest rate to doctors.

“I don’t think most physicians know what they’re being reimbursed. Only when they start seeing some of those rates come through will they realize how low the rates are they agreed to.”

Gerard’s decision to reject two plans is something officials in Connecticut are concerned about. If reimbursement rates to doctors stay low in Obamacare plans, more doctors could reject those plans. And that could mean that people will get access to insurance, but they may not get access to a lot of doctors.

That worries Kevin Counihan, who runs Connecticut’s health insurance marketplace.

“I think it could lead potentially to this kind of distinction that there are these different tiers of quality of care,” Counihan says.

His agency recently approved rules geared at getting more providers into plans on the exchange. The goal is to make sure that everyone gets good care regardless of their income.

He doesn’t want the impression left that someone who gets a subsidy to buy ACA coverage will get inferior care. “That’s been something, at least in our state, that we’re trying to work against. And the carriers are, as well,” Counihan says.

All three of the insurers on Connecticut’s exchange were asked to comment. Two declined. One agreed. Ken Lalime is the CEO of Healthy CT — an insurance co-op. He says insurers face a real challenge figuring out how to pay doctors enough but also keep consumer premiums low.

“Every time you increase payments to providers, you have to offset that with increased reimbursements from the consumer,” says Lalime. “So there’s this balance between how much do you want to cost to provide that service and how much you can pass along in your premiums rates. It’s a balancing act.”

Healthy CT may have missed the balance – just 3 percent of the exchange’s consumers bought the co-op’s insurance in 2014. Lalime says he also thinks low reimbursement rates are forcing some doctors to decide against accepting insurance under the Affordable Care Act.

Dr. Bob Russo is sure of it. He’s a radiologist and he’s also the president-elect of the Connecticut State Medical Society. He says that the low rates and administrative burdens that come along with the ACA could make it a financial loser.

“You get what you pay for,” Russo says. “If you can’t convince [doctors] that they’re not losing money doing their job, then it’s a problem. And they haven’t been able to convince people of that.”

He, like Counihan, worries about creating a tiered health care system. He says, think about Medicaid. Before a recent rise in rates, it paid doctors even less than Medicare, so many stopped accepting Medicaid patients.

“There’s no question that Medicaid, under its old rates, wasn’t working. So, have we just invented a new Medicaid that kind of slid the scale up a little more to make access a little more?” Russo says.

The experience of these doctors is a good reminder that the Affordable Care Act is more than a thought exercise in health care. It’s happening. And here’s another reminder: open enrollment for 2015 begins in just over three months.

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Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente. (Photo by Will O’Neill via Flickr)

11 comments

  1. When you pay peanuts, you hire monkeys.

    Doctors’ personal income is only about 8% of total healthcare costs according to CMS.

    So if all doctors were to work for free forever, from now on, health care costs would drop 8%, ONE TIME.

    I talked to a couple of doctor friends a little while ago, we all drive a Lexus. Mine is the newest, it’s a 2001.

    Next time you or a family member is sick, do us all a favor, call your congressman. Don’t call a doctor, we’re all too busy with our fancy cars. Or move to France.

  2. Wrong way to pay… the VA system has salary doctors that pay attention to service and cures, not profits and repeat business.

    Private doctors see up to 12 patients an hour, the VA about 4, and the quality goes UP when a doctor can spend time with the patient.

    Medical Insurance companies need to look at the doctor’s success rates, not the number of codes filled out on the invoice.

    If a patient is coming back over and over, or going to doctor after doctor, then something is wrong, and it is usually, from my experience, that the doctors are NOT Listening to the Patient, usually a young or very old patient, and therefore is missing the FACTS that are causing tens of thousands to not get cured or to die ….

  3. The average doctor in a private practice makes 136,000 a year income (after expenses). Knock this down down 20% (getting $80 per visit instead of $100). Now the lights go off because he is having to limp along with only $108,000 a year. I’m sorry but doctors will have to expect only twice or three times as much money as the rest of us make.

    • Sean,

      Your math is inaccurate. If you drop total revenue by 20%, the fixed and variable costs of a medical practice are easily rising between 3 and 5 % a year, that would cause a doctor running at a 40% profit margin who was previously making $136,000 a year drop down to $68,000 a year. What doctor do you know wants to go through the rigorous schooling, exams, residencies, schedules, etc. for that kind of money? Not to mention with highs and lows during the year, a monthly profit of only $5K will literally cause docs to have to worry about “keeping the lights on” during a down month or if a piece of equipment goes bad.

      We want our doctors to make money. They provide jobs and better health for the community. I work for a group of ENT doctors in Salt Lake Citydocs and these are real issues that affect more than the doctors’ piggy banks.

      • That is BS. In France, University and Medical School is FREE. No they don’t make the money American docs make… but the education is every bit as hard as it is over here… One huge difference; In France they do it because it is a calling… Not so much in greed sick America.

        FYI

  4. These doctors act like they’re struggling to get by. Has anyone ever meet a poor doctor?

  5. I guess those new Jaguars will have to go to someone else!

    • They can go to the drug dealers maybe???? And would you give up 12 years of your life so you can drive a piece of crap????

    • The next time you have an ache or a pain go to the internet not someone who is educated and can and will help you. The internet is free and you probably don’t resent it like you obviously resent someone who has made the sacrifice so that the government morons can tell them how to practice their profession.

  6. This is what happens when you have too many hands in the pot! If we had a single payer system like the rest of the western, sane countries, we wouldn’t have this issue.

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