Maverick local doctors and therapists prescribe a wellness coup.
Thursday, January 21, 2010
For the peasant women of a Himalayan village in 1974, it took a logging threat to inspire the first act of tree-hugging. For East German church-goers in 1989, a prayer service in the streets helped precipitate the fall of the Berlin Wall. For Carmel gynecologist Dr. Stephanie Taylor, the call to peaceful resistance came on an autumn morning, when she walked into her office at 8am to find her staff already exhausted amid thick stacks of paperwork.
“I just said, ‘You know what? It’s not working. We’re not going to do this anymore,’” she recalls. “They looked at me with big eyes and said, ‘What are we gonna do?’ and I said, ‘I’m going to quit my insurance contracts.’”
While Congress bangs out the final details of a national health care bill, Taylor and several other local health care providers are attempting creative escapes from the health insurance industry’s stranglehold. Not only are patient premiums ballooning, but reimbursement payments to private practitioners are shrinking, putting a squeeze on the quality of their services.
In a letter to her patients, Taylor announced that effective Jan. 1, 2010, she’s dropping all of her insurance carriers – about 25 total. “There’s a belief that you have to have insurance contracts, but it’s just not so,” she says. “It’s a bit of civil disobedience from the good old days. [Henry David] Thoreau. That far back.”
Surprisingly, she says, the numbers work out: While she expects to lose almost half her patients, she’ll save the 25-30 percent of overhead costs that went to billing insurance, without laying anyone off. Patients pay at the time of service, and get 30-to-60-minute sessions rather than the fleeting 15 she could afford under the insurance contracts.
Taylor, an East-meets-West sort of doctor who teaches Tai Chi on the weekends, is also integrating new preventive programs into her practice, including quarterly medical lectures for patients. “What I want to do in advocating for health is to see the other part of the picture, which is not just diagnose someone and give them a pill, but really look at their lifestyle, diet and exercise – which I hadn’t been doing,” she says. “I thought it was a moral failure on my part, but it was really just not enough time.”
“IT’S A BEAUTIFULLY SIMPLE SOLUTION, ASSUMING YOU’RE WILLING TO JUMP OFF THE CLIFF.”
Her patients can still make insurance claims, but they’ll have to do their own paperwork (after one courtesy billing by her office), and likely pay up to $20 extra for using an out-of-network provider.
“It’s a beautifully simple solution,” Taylor says, “assuming you’re willing to jump off the cliff.”
: : : :Pizza eases the stress a little, but not much, for a group of local physical therapists digesting changes to Anthem Blue Cross’s contract.
Like PTs across the state, they’re grappling with new rules, effective Feb. 1, that reduce their reimbursement caps to $75 per patient visit – an estimated 30 to 35 percent cut – and limit care to 12 sessions per patient, among other measures. They say the changes could force them to spend less time with their patients, resulting in lower-quality care and higher malpractice risk.
“Blue Cross is trying to take away our independence,” says Monterey PT Shelley Kroopf. (Full disclosure: I’m a former patient.) “You have a bunch of nincompoops who have no idea what we do, trying to take away all our autonomy. Where do they come off doing that?”
Even more maddening: While their own insurance payouts shrink, they’re seeing subscriber costs skyrocket. Brenda Krpata, office manager for her husband Charles’ practice in Carmel, says Anthem premiums for her employees are up about 25 percent this year. “Where’s the money going?” she asks. “It’s not an equal playing field there.”
Kroopf complains that Anthem and other insurance companies are exempt from federal antitrust laws that prevent monopolies and unfair business practices, while doctors and therapists are barred from collective bargaining. “A lot of people say providers charge too much,” she says. “It doesn’t matter how much we charge – they pay us what they want to pay us, take it or leave it.”
Anthem has particular clout, the PTs say, because it covers one-fifth to one-third of their patients. “Here is a large, powerful insurance company looking for the easiest place to reduce their cost,” says Carmel therapist Bud Ferrante.
Now, they’ve decided to draw the line. Krpata, Kroopf and Ferrante plan to reject Anthem’s new contract – and they say about a dozen other local PTs are joining them. It’s a calculated risk, but they hope it will force Anthem’s hand.
In a letter to local colleagues outlining their gripes, they write: “We believe that if EVERY physical therapy office in Monterey County refuses to sign the proposed BC contract, BC will have to reconsider and present a revised contract that is fair and reasonable to BC and to us.”
They toe a thin legal line. “Because of antitrust and collusion, providers aren’t allowed to get together and discuss what we’re going to do,” Krpata acknowledges. “[But] if they don’t have any physical therapy providers in this area, Blue Cross would have to do something different.”
: : : :At Ryan Ranch Medical Group, Dr. Tel Franklin is sticking with the existing system, but with a twist: As part of the national MD VIP network, he charges his patients $1,500 per year out of pocket, while still billing insurance for office visits.
“MD VIP is personalized health care,” Franklin says. “Instead of going to a physician with another problem, it’s a way of getting ahead of the curve and working on a personalized health plan.”
Thanks to the yearly fee, he says, shrinking reimbursement rates don’t have to dictate the amount of time he spends with patients. Rather than seeing up to 3,000 per year, he now devotes his time to about 500 VIPs, who enjoy 90-minute “executive” physicals, 30-minute office visits, medical history CDs and customized wellness programs. The goal, he says, is to shift the focus of care from illness and crisis to prevention and health.
“For those patients I’m on call 24/7,” Franklin says. “They all have my cell phone number, same-day appointments, and I’m really their personal physician. They’re not gonna get someone who’s on call. I know these people.”
: : : :Providers, patients and politicians cast insurance companies as the greedy profiteers of the health care crisis, but Anthem spokeswoman Peggy Hinz blames spiking medical expenses from hospital stays, pharmaceuticals and new medical technologies.
State and federal laws keep insurance companies in check, she says. The profit margin for WellPoint, Anthem’s parent company, is about 4 percent of revenue – $2.5 billion in 2008.
“We’re heavily regulated by both the [state] Department of Insurance and the Department of Managed Health Care,” Hinz says. “The profit margin [for insurance companies] relative to other companies is quite modest. We want to make sure we’re compensating all medical professionals fairly while keeping costs affordable for our members.”
But when asked for responses to specific provider complaints, Hinz shuts down. Regarding “silent PPOs” – in which insurance carriers apply their low reimbursement rates to other carriers without a doctor’s direct knowledge or permission – and insurance company policies that push patients away from private practitioners and toward big clinics and hospitals, Hinz replies: “I’ve never heard of that… I’ve not heard anything like that.”
She ends the phone conversation, asking that other questions be sent via e-mail. Later, she e-mails a statement in response to the PT complaints: “Anthem recently made adjustments to its physical therapy reimbursement rates to standardize the pricing structure and to help contain escalating health care costs. Under the new structure, if the amount paid to the therapist is reduced, then the member will experience a corresponding decrease in their out-of-pocket expense.”
Seven more detailed questions go unanswered. “We will have nothing more to add at this time,” Hinz writes.
: : : :While Anthem slams the door of its Thousand Oaks headquarters, local health care provider Central California Alliance for Health – based in Scotts Valley, with offices in Salinas and Merced – is happy to take questions.
As a “county-organized health system,” CCAH links about 65,000 Medi-Cal beneficiaries and 18,000 children in the state-sponsored Healthy Families program to local primary care providers. And that’s just in Monterey County. The nonprofit also serves residents of Santa Cruz and Merced counties, working under contract with the state as a sort of Medi-Cal managed care plan.
“We’re trying to be the good guys in the health insurance world,” says CCAH Executive Director Alan McKay. “We don’t have the for-profit orientation of needing to maximize net income.”
But don’t assume bureaucracy means inefficiency: McKay says the Alliance spends less than 6 percent of its budget on administration, and costs less to taxpayers than Medi-Cal. “In a small but significant way, we’re trying to contribute to the state’s economic recovery,” he says.
The state Department of Health Care Services has ranked CCAH number one out of 36 county-organized health systems in the state for the past three years, he adds proudly. And while providers don’t get rich off the program – CCAH reimbursements are negotiated discounts that usually fall at or below commercial health plan rates – quality-based bonuses reward successful preventive care. “One of the advantages of our nonprofit model is that we don’t have to focus on quarterly dividends, but on cost-effective care,” McKay says.
In a health care landscape that’s straining both patients and providers, CCAH seems tantalizingly close to a public option. But it’s a safety net, not a general health care plan, available only to low-income Central Californians with qualifying conditions, such as the elderly, the disabled and single parents.
: : : :That net may grow soon. As the U.S. House and Senate reconcile their versions of a national health care reform bill, there’s a strong chance county-organized systems like CCAH will become available to anyone who lacks employer – or government-sponsored health insurance.
“It’s possible that the Alliance could be a choice for the uninsured under the Health Insurance Exchange, which Congressman [Sam] Farr has described as a sort of Expedia,” McKay says.
The idea of a national exchange is to allow individuals to comparison shop for health care, browsing through a menu of insurance options on a government website. And unlike a public option requiring insurance for every American, the voluntary exchange is alive and well.
On Jan. 15, the White House announced it’s opted for a national exchange, reports Farr (D-Carmel). “It’s a work in progress,” he says. “The law doesn’t force people to use the exchange, but they could apply.”
CCAH likely qualifies under the bill as an Accountable Care Organization, Farr says. And it looks like there will be funding in the bill for expanding its services, though the details are still soft: “We won’t know that until they write the regulations.”
Hopefully the bill will also hike Medicare reimbursement for providers in the tri-county area, which gets some of the lowest payouts in the state. “This is a huge thing for doctors, who are refusing to see Medicare patients because the reimbursements are so low,” Farr says. “It’s all coming together for us. It’s looking good.”
For the new model to work, CCAH needs a strong network of participating local providers – and the bottom line may not improve for practitioners like Taylor, Franklin and Kroopf. But at least it cuts out the insurance carrier’s profit element, opening up health care services for Monterey County’s estimated 82,000 uninsured residents – 7,000 of them children, according to the 2007 California Health Interview Survey.
That would probably please Henry David Thoreau, Dr. Taylor’s civilly disobedient inspiration, who prized simplicity and health over material wealth. As Thoreau once wrote: “A man is rich in proportion to the number of things he can afford to let alone.”