Confessions of a rebound doctor: The impact of narrow networks

“We lost our regular doctor with Obamacare, so now we have to see you.”

I routinely ask my new patients how they heard about our pediatric office, and this is the answer I dread most. My pediatric practice is a very nice and modern private office, and in my opinion, full of excellent physicians. I entrust my own children’s care to my partners. But none of that matters when you’re the rebound doctor, the only option for patients after Obamacare jilts the lifelong relationship with the doctor they truly loved.

After an answer like this, an awkward silence follows as I try to navigate some sort of apology-welcome-to-the-new-office type response. It’s a horrible feeling to have a new patient against their wishes.  These awkward conversations burn in my throat as I hear the president’s intentionally false campaign promise ring in my ears, “If you like your doctor, you can keep your doctor.” Our president knew it was untrue was he said it, those of us in the medical field knew it was untrue when we heard it. Now I have to face Americans who really liked their doctor, wanted to keep their doctor, but now banned from seeing their doctor due to Obamacare and forced to bring me up to speed on years of medical and personal history on their children.

It’s particularly frustrating because these are hard-working families pushed into the exchanges.  Some have lost their employer-based health insurance as they were cut to part-time hours due to Obamacare. Others are self-employed individuals losing their old affordable high-deductible plans made illegal by Obamacare.  The most ironic are the employees from the largest health system in our city, which is aggressively cutting employees to part-time so they can dump their health insurance.

The cheapest exchange insurances are the narrow network products, costs are kept down by severely limiting choice. We currently participate in a narrow network insurance product, the only pediatric option in a city full of amazing pediatricians and family doctors. Choosing the narrow network exchange insurance means these families are almost guaranteed to lose their trusted family doctors in order to obtain some form of health insurance. For the employees at that health system cutting hours … it means their employees cannot see the doctors within their own hospital!

As a professional, I do my very best to earn the trust of every family in my office. But the overwhelming uncertainty of Obamacare weighs on me. I know many of these families can only afford the exchange insurance because of taxpayer-funded subsidies and those subsidies are likely illegal. Michigan is a state that wisely opted to have the federal government run the exchange.  I say wisely, because the logistical nightmare of inventing the Exchange was clear from the beginning. The colossal and expensive failures of state-run exchanges in OregonMassachusettsMaryland, and Rhode Island are real life case studies pointing to the wisdom of our state legislators here.

However, Obamacare as written, does not allow taxpayer subsidies to be used on federal exchanges.  The Obama administration is currently ignoring their law and giving subsidies to those purchasing insurance on federal exchanges anyway. The recent Halbig ruling brought the issue to light, but hasn’t clarified it. The subsidies still hang in political limbo, which means my new patients are in limbo as well.

The solution seems so clear in my little corner of the world. I want my patients to have control over their own health care dollars regardless of employment status or political party in power. I want to work directly with my patients to help them choose how to best use those dollars in a price transparent health care environment. I want them to choose me. I want competition to push me to provide the best care at a good value, knowing that my patients always have a choice to see another doctor if I’m not doing a good job. In short, I’d love folks to own a high-deductible HSA for life, in a health care system that is transparent and competes for those dollars.

But that would give power directly to the patient and all the health care choices between the patient and the doctor. Turns out, there are more powerful players that want control over what happens in my office. I think about this sometimes, as I sit down with a new patient being thrown about in the system. There are so many other people in the room with us telling us how the be patient and doctor, from the IT companies and the mandated electronic records, HITECH, the insurance companies and the proper codes, meaningful use, Choose Wisely, insurance company incentive programs, preferred drug lists and prior authorizations, in-network providers and out-of-network providers, on and on. It’s overwhelming.

And so I take a deep breath and focus on what I can control, welcome the new family to the office, help the toddler pick out her Doc McStuffins sticker and hope for a day when a bureaucrat somewhere isn’t the one to determine how long this relationship will last.

Meg Edison is a pediatrician and can be reached on Twitter @megedison.  This article originally appeared on Rebel.MD.

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  • QQQ

    “It’s particularly frustrating because these are hard-working families
    pushed into the exchanges. Some have lost their employer-based health
    insurance as they were cut to part-time hours due to Obamacare.”

    “Mommy mommy, how come you have a card to go see the doctor…you said we is poor”

    “Well sweetie, some nice folks who live way on the other side of town
    took on extra work and live a little less better…just for us. People
    are good like that”

    “Wow mommy, when I grow up I am going to be just. like. you.”

    “Of course you will baby. Now come with mommy to the voting place and
    watch me pull all the levers on those politicians in big daddy government so you’ll know what to do when its
    your turn”

    • doc99

      “The government that robs Peter to pay Paul can always count on the support of Paul.” George Bernard Shaw

  • Ron Smith

    Hi, Meg.

    Thanks for your article. A couple of questions I had in reading your article came to mind which would help me gather some thoughts about this. I have appended my own answers to the questions so that you’ll know that I’m asking these in good faith and to truly frame the article. If you feel reserved about answering any of these, I can understand.

    1. How long have you been in Pediatrics? (I’m now in year thirty-two.)
    2. How old are you? (I’m 56.)
    3. How does the demographics of your office break down? (My office has two full time nurse practitioners–soon maybe to be three–and myself. We have <10% Medicaid.)
    4. What is the general location, city and state, do you practice? (I'm in McDonough, Georgia, about 20 miles south of Atlanta.)
    5. Do you see babies in the hospital and round on Pediatric patients. (I do not and have not now for about 7 years.)

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

  • Ron Smith

    Hi, Meg.

    Yes, I skipped my senior year in high school, went straight into college where Stacy and I married, straight into medical school, straight into Pediatrics residency and straight into solo practice.

    I don’t see newborns even in the hospital now, because the short maternal stays prevent any kind of decent education. I see them within the first week in my office.

    Currently I’m getting about 18 to 23 new patients a week and with my two fulltime nurse practitioners, the practice is seeing about 10,000 patient visits a year.

    I developed and deployed my EMR (I’m a database programmer too) in 2000 and it is a unified EMR/practice management solution.

    Several years ago, I began an employee incentive program. All employes enjoy a participation in the profits of the practice. This has been a major influence in why we get so many new patients.

    The comments about why patients come to us are not generally about loosing a previous doctor, but rather, ‘we heard about your from our friends.’

    The success of the office is not just the high technology we employ though that is significant in keeping costs down, but the quality of the experience. Patients constantly comment about how peaceful the staff are and how great their experiences are.

    I credit this greatly to my practice manager. She is not an office manager, but I have even submitted myself to her. She has the authority to call even me on the carpet if, for example, I’m getting to the office late, or not keeping up with the schedule.

    She balances a true schedule where patients get time slots which allow us adequate time to see them without encroaching on other patients’ appointments. We don’t double book. I see about 25 patients a day as do the nurse practitioners. We work as a team and there is no practice turf.

    We currently take one Medicaid CMS provider here in Georgia. When Peachstate and Wellcare started playing the game of delaying payments by changing claims requirements, I cut them off. This practice is also a business that has responsibilities to the staff. If we aren’t successful financially, then their familiies suffer. They are just as important to me as the patients’ families.

    Though my accountant and my practice manager watch and manage the finances, I keep my fingers out of the pie during the year. I only know that it is doing well, and I focus on good patient care. My salary is fixed and like the staff at the end of the year, I enjoy profits that we are all receiving.

    Good business management is about getting good tools (not just the EMR) and incentivized employees who think of this as their work home. It translates into good patient care.

    Simply having a mission statement ‘to provide the best medical care possible’ is inadequate. Physicians must be sound business executives as well as good doctors.

    If we don’t concentrate on all the basics, then everyone suffers, I think. Hope these comments are constructive! :-)

    Warmest regards,

    Ron Smith, MD
    www (adot) ronsmithmd (adot) com

  • KMarton

    Hmmm–so having to change doctors is all due to Obamacare.
    I think back about 10 years ago, when i had a discussion with one of my brothers–a successful attorney. As he often did, he’d call me for medical advice. And, as i often did, I’d answer his questions, but add..”and why don’t you discuss that with your own doctor?”
    His response: Well my insurance company has forced me to change doctors 3 times this year so far, and i don’t really know her yet.”

    It’s just a reminder that “the good old days” of employer based private insurance were not that good, and that many of the abuses attributed to the affordable care act have been with us for a longer time than the act has.

  • Sara Stein MD

    Oh please. This has nothing to do with Obamacare. Businesses have been changing insurers for years due to rate hikes, which forces reassignment of PCPs. I’m not sure what your complaint is – why can’t you just say welcome to our practice, and get on with business instead of handwringing. Conversely when my patients have to leave due to change of insurance, I wish them well, give them a deadline on medication management from me, and have them sign a release of information for their new doctor before they leave, to help with continuity.

    Your subsidy information is wrong too, at least in Ohio, The federal subsidy is calculated on the ACA Obamacare website and deducted from the total cost per month at sign up. Yes, you have to provide proof of income within a certain time if you have accepted a subsidy. Sounds as if your states’ website is rigged.

    What it sounds like you have is regulatory burnout. We all do. But it certainly is not the fault of Obamacare. The regulations have been coming for the past 15 years at lightning speed.

  • Ava Marie Wensko George

    The answer here is single payer. Period. High deductible low yield insurance of the past should be illegal. We need to find a way to cover all Americans so that we can stop disease from financially destroying families. We cannot continue to be one illness away from bankruptcy. In America 60% of bankruptcies prior to the ACA were due to catastrophic medical events. So, while so many bash the ACA, at least it is the start of a solution, and would have been made better had our Congress worked together like they did with the Medicare roll out during the presidency of President Bush.

    • Patient Kit

      I agree. I’m at a point where nothing less than a single payer universal comprehensive healthcare system will be acceptable to me in this country. I’m really sorry I didn’t have a chance to get involved in the recent NHS (UK) thread that closed prematurely after only about 3 days of apparently heated discussion.
      I’m convinced that most of the vague horror stories about other countries’ national healthcare systems are coming from those in the US who have vested personal interests and agendas, financially and/or politically, in doing anything they can to keep universal healthcare from happening here in the US. They will do anything they can to keep healthcare a profit-driven big business in this country. And one of their major tactics is a very nasty campaign of extreme fear-mongering about national healthcare and trying to deflect attention off of the truly horrific medical and financial stories that patients in our own system are suffering.

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