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You are here: Home / Anderson On Health Insurance / You’re pathetic, now go away

You’re pathetic, now go away

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The Red Pen is worried about access to doctors who are listed on the Exchange eligible directory but aren’t actually available:

I’d still like a good answer to the wingnut attack vector about “doctors hate Obamacare.” The result, they say, is that doctors won’t take patients and that people who buy insurance on the exchanges will not be able to get the treatment that they signed up for, even though it’s now covered.

There are doctors who either did not sign up for Exchange products or actively opted out of Exchange products.  There are networks with significantly lower than commercial reimbursement rates with only a few providers per specialty in it.  There are networks that are pay straight commercial rates (my company is selling both network flavors on the Exchange.  There were large exclusions for the low cost version, and a rounding error worth of opt-outs in the regular cost version.) But most of the networks have mostly settled.

But there are a few things to be wary of in network but not really providers:There are three variables that determine provider availability for people with a certain insurance.  The first is the simple question of whether or not the provider takes that type of insurance.  This has been assumed as a yes in this question.  The provider is par in a particular Exchange product. This means that once a service is rendered and the insurance company or the member pays the contracted rate, the provider can’t go after the patient for any more money.

The second question is whether or not a provider has an open or closed panel.  An open panel means the provider is taking new patients.  This can vary by product as my company has providers with open Commercial but closed Medicare panels.  The panel composition question is an interesting exercise in optimization based on potential revenue, potential skips, case complexity, and coordination issues.

Panel status is a soft barrier, as a closed panel is only mostly closed.  When I wrecked my hip as a child, my local orthopedist knew the repair was passed his skill set.  He called a med-school buddy whose name is cursed by fantasy football owners everywhere as a visit to him by your WR2 means the WR2 is done for the year.  The high end orthopedist had a softly closed panel, but his buddy said that I had a great teaching moment injury, so I was his patient for the next two years because I had a “fascinating” injury.

The final variable is whether or not a patient can get an appointment.  Assuming the provider is par and has either an open panel or a closed panel but the patient is being treated by that provider, an appointment is the moment of truth.  Can I see a doc for a specific problem when I need to?

This is the office manager checkpoint as they often have a good awareness of what types of insurances and reimbursement schedules are coming into the office and if they are only getting Medicaid, Medicare or narrow network Exchange patients, there is a strong incentive for them to schedule you out four weeks from now instead of tomorrow afternoon in order to either keep that spot open for a higher paying commercial member or to give a soft push to switch to another provider.  The office manager checkpoint is a real barrier to entry for Medicaid patients.

For the narrower and lower reimbursement fee schedule Exchange products, the appointment avaialability problem will most likely be real for some providers.  The doc will treat them if they can get in to see the doc, but the system is tilted against allowed them easy access to the doc.

Reader Interactions

38Comments

  1. 1.

    Betty Cracker

    Might want to insert a space between “Pen” and “is” before unintentional hilarity ensues…

  2. 2.

    Dave

    The Red Penis worried about access to doctors who are listed on the Exchange eligible directory

    Typo FTW!

    edit: Betty Cracker harshin’ the glow…

  10. 10.

    Botsplainer

    I want conservative asshole doctors to quit. The faster it happens, the faster the guild gets broken due to dire need, and medical services come down to true market rates.

  12. 12.

    dr. bloor

    @Botsplainer: If you think reimbursement rates for doctor services are driven by Randian price-gougers, my only question for you would be what color the sky is on your planet.

    As for fee exchange patients having a hard time getting a fast appointment, same as it ever was.

  13. 13.

    Jerzy Russian

    I am not sure Mr. Mayhew has given Red Pen his/her good answer to the wingnut attack that “Doctors hate Obamacare”.

  14. 14.

    Sister Rail Gun of Warm Humanitarianism

    @dr. bloor: Break the guild, break the artificial shortage of doctors. Or, shift the membership, shift the approach to its mission, still with an eye toward breaking the artificial shortage.

    I’m not sure that we want to see the medical profession in the same state as the legal profession, though.

  16. 16.

    dr. bloor

    @Sister Rail Gun of Warm Humanitarianism: It’s not a calling, not a mission, it’s a profession. Medicine competes with other high-end professions for intelligent, talented young people. As it stands now, primary care docs are so marginally reimbursed for the training/debt/time commitment involved and the day-to-day headaches, you basically have to be clinically insane or on the fast-track for sainthood to become a family doc.

    As for specialists, you’re only going to get people you really want to be digging around in your brain to remove a goober as long as they’re paid accordingly. You can have Harvard Medical adopt an open-admissions policy and somehow conjure free medical education, but you’re still asking intelligent young people to sacrifice their earning power well into their thirties. As a society, I’m pretty sure you need to offer the promise of making more than a plumber or SAT coach.

    The “throw the doors open to everyone and drive down prices” is the stuff of Planet Sparkle Pony.

  18. 18.

    Robert Sneddon

    During the formation of the NHS in 1948 in Britain a number of doctors swore they’d retire, emigrate or otherwise “go Galt” when the Socialists (real socialists, not slightly left-leaning conservatives like Democrats in the US) introduced free healthcare for all. Maybe they did follow through on their dire threats, the rest of the country didn’t notice their absence.

  19. 19.

    Sister Rail Gun of Warm Humanitarianism

    @dr. bloor: Hence my doubtful comment, comparing the end game of such a policy with the glut of recent legal school graduates.

    That said, I’d still prefer something akin to the European models over what we have now. Break the guild, we have a chance of improving things.

    @Robert Sneddon: I’ve been taking great glee in pointing out that a lot of the doctors who have flounced out of the profession did so over the records-keeping requirements. Hmm, wonder why they wouldn’t want to improve their records-keeping efficiency? Couldn’t be that the aim of those requirements is to detect Medicare and Medicaid fraud, could it?

  21. 21.

    catclub

    @Botsplainer: “I want conservative asshole doctors to quit. The faster it happens, the faster the guild gets broken due to dire need, and medical services come down to true market rates. ”

    This sounds like a ‘heighten the contradictions’ solution. We need to create or import more doctors ( plus empower nurses and PA’s). Having more doctors will lower the prices. Not fewer.

  22. 22.

    catclub

    @dr. bloor: “The “throw the doors open to everyone and drive down prices” is the stuff of Planet Sparkle Pony.”

    Let’s open up immigration for doctors trained in other nations just to see how unrealistic this idea is.

    Are you suggesting the Brain surgeons in France working on Micheal Schumacher are incompetent because they only get a third or so of US surgeons compensation?

  24. 24.

    J R in WV

    @catclub:

    The surgeon who saved my wife’s life is from the Philippines, where he went to school. Then here he did a residency at a well known teaching hospital. Wonderful and compassionate doctor, thoracic surgeon, one of the best chest guys anywhere.

  25. 25.

    StringOnAStick

    I’ve got a friend who is a respected radiation oncologist in Canada. His salary isn’t what it would be in the US, but he practiced here and then moved back to Canada because he couldn’t handle the unfairness of our system – pay or die was something he couldn’t reconcile. He also gets a 3 month sabbatical every 5 years, on top of generous vacation time. Docs here don’t get that unless they somehow figure out how to work it into their schedules. This is what makes the lower salary worth it to my Canadian friend, plus the fact that he doesn’t have to turn people away due to lack of insurance.

  27. 27.

    Stella B

    @catclub: About 25% of newly licensed physicians each year are foreign medical graduates. Although we could absorb more FMGs into primary care residency slots (chronically unfilled), they aren’t interested. The only barrier to a medical license that FMGs are required to pass, other than the usual requirements for an American doc, is a TOEFL — not an unreasonable request.

  28. 28.

    Sister Rail Gun of Warm Humanitarianism

    @Villago Delenda Est: Not an effect of relaxing admission quotas. We have a glut of young law graduates. I don’t think we want to see a similar glut of young medical school graduates without some sort of relief for their enormous educational expenses. If nothing else, it’s a net negative for the economy.

  29. 29.

    Stella B

    @catclub: Do you have a reference for your compensation numbers? The one that I have shows physician incomes as a multiple of average household income in the country. If you look at it that way, Europeans make just about what US docs make.

    2010 numbers, by region, across specialty:
    NE US $204K (lowest in US)
    Upper Midwest $238K (highest in US)
    Ontario $225K (in US $)

    Nice salaries, admittedly, but $225K is not substantially less than $204K….

    There are Republican doctors out there — more of them in Texas than Massachusetts — but they are still mostly on the D team according to the polls. In the context of what Americans get paid, they do get paid well, but that’s true of physicians world wide. It’s a long and demanding training (which probably needs to be increased, not decreased) and demanding job. In the Soviet block countries it was traditionally women’s work and paid accordingly, but in the west, it has traditionally been well paid. French and Japanese docs are also offered very favorable tax treatment by tradition.

    Physician compensation is only about 10% of medical costs anyway.

  30. 30.

    Ruckus

    @dr. bloor:
    This.
    How has the ACA changed actually getting an appointment? Not at all? Worse? I don’t see better as a possible answer. The only time I used to get an appointment whenever I wanted was when I paid cash at the time of appointment. Instant money in the full amount was always better for the Dr than having to wait for weeks for an insurance co to pay.

  31. 31.

    schrodinger's cat

    @Stella B: Foreign physicians, even the ones who have been practicing for many years in their home countries have to take the USMLE and complete the 3 year residency requirement in order to practice medicine in the US, so it is not as easy as just taking the TOEFL.

  33. 33.

    dr. bloor

    @Stella B:

    Physician compensation is only about 10% of medical costs anyway.

    This, a million times. Anyone who thinks that doctor salaries are the chief culprit behind health care costs simply has no understanding of the workings of the “industry.”

  34. 34.

    dr. bloor

    @catclub:

    Let’s open up immigration for doctors trained in other nations just to see how unrealistic this idea is.

    As others have noted, the doors are open. They don’t want our primary care jobs because incomes in that area are lagging vis a vis other countries.

    Are you suggesting the Brain surgeons in France working on Micheal Schumacher are incompetent because they only get a third or so of US surgeons compensation?

    Nice straw man you’re trying to build there, but no, not at all. French medicine is very, very good. As it turns out, French doctors also do very, very well when you look at their incomes as compared to talented, high-end wage earners in France.

  35. 35.

    Mnemosyne

    @dr. bloor:

    In the US, I’m guessing that as with most of our institutions, the problem is less doctor (and nurse) compensation and more administrator compensation. When the hospital’s CEO is getting paid 5 times more than your top brain surgeon, that’s a problem.

  36. 36.

    FlyingToaster

    Up heah in the People’s Republic, for the first two years of RomneyCare there were problems getting some of the previously uninsured into physicians’ offices, simply because there weren’t enough appointment times to go around.

    It only took two years to get sufficient staffing up in practices (the one HerrDoktor and I go to grew from 3 to 4 PCPs plus a NP during those two years; since they’ve added 2 more PCPs and a locum) to meet the initial demand. A number of our private practices are hospital-affiliated; this means you’re already in a covered network when you’re sent to a specialist from that hospital (and therefore that same network). Our practice is affiliated to a specific teaching hospital; we haven’t gone out of network EVER (take that, BCBSMA).

    Clinics, HMOs and private practices were able to grow with RomneyCare to match the needs of our 6 million folks, 93% insured (98% of children, mind you).

    Will this work nationwide? I can’t absolutely predict, but my money is that in 2 years the states with their own setups (MA, VT, etc.) will probably be up to snuff, if they aren’t already. But Texas and Florida may take 20 years — or a D sweep of their statewide offices and legislatures — to meet the needs of their populace.

  37. 37.

    Monala

    @Ruckus: My husband–who is diabetic and has been uninsured for 3 years–called for an appointment today with a primary care doc with his new ACA insurance. His appointment is Tuesday, Jan. 7th.

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