Doctors pay under ACA.
Doctors Complain They Will Be Paid Less By Exchange Plans
By RONI CARYN RABIN
NOV 19, 2013
Many doctors are disturbed they will be paid less â often a lot less â to care for the millions of patients projected to buy coverage through the health lawâs new insurance marketplaces.
Some have complained to medical associations, including those in New York, California, Connecticut, Texas and Georgia, saying the discounted rates could lead to a two-tiered system in which fewer doctors participate, potentially making it harder for consumers to get the care they need.
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âAs it is, there is a shortage of primary care physicians in the country, and they donât have enough time to see all the patients who are calling them,â said Peter Cunningham, a senior fellow at the nonpartisan Center for Studying Health System Change in Washington D.C.
If providers are paid less, âare [enrollees] going to have difficulty getting physicians to accept them as patients?â
Insurance officials acknowledge they have reduced rates in some plans, saying they are under enormous pressure to keep premiums affordable. They say physicians will make up for the lower pay by seeing more patients, since the plans tend to have smaller networks of doctors.
But many primary care doctors say they barely have time to take care of the patients they have now.
The conflict sheds light on the often murky world of insurance contracts in which physicians donât always know which plans theyâre listed in or how much theyâre being paid to treat patients in a particular plan. As a result, some doctors are just learning about the lower pay rates in some plans sold in the online markets, or exchanges
âIf youâre a physician and youâve negotiated a rate from insurance, shouldnât it be the same on or off the exchange?â said Matthew Katz, executive vice president of the Connecticut State Medical Society. âYouâre providing the same service.â
Blues: No Desire âTo Gougeâ Docs
A senior executive at Blue Cross Blue Shield Association said some of its 37 member organizations â each of which operate independently and offer a variety of plans â are offering lower rates to physicians in smaller exchange plan networks.
But, she said, plans know that a good network of providers is essential or customers âwill go someplace else,â and they are enlisting sufficient numbers of doctors.
âWeâre not motivated to gouge the doctor,â said Kim Holland, Blue Cross Blue Shield Association executive director for state affairs. âWe depend on good relationships with quality physicians. ⌠I canât imagine any product we offer is going to have a physician rate that would discourage them from seeing a patient.â
But some physicians see things differently. Contracts between insurers and doctors vary with some allowing insurers to adjust rates unilaterally or to assign a doctor to multiple plans.
âIâve participated with Oxford since 1985. They donât send me a contract every year to sign. They donât send me the rates. You donât know the rates,â said Dr. Paul Orloff, a physician who is president of the New York County Medical Society. âItâs the only game in town so you sign. They have a right to unilaterally change the rates at any time during the contract.â
The benchmark for physician fees is the rate the federal government sets for services provided to older Americans through Medicare. In many markets, commercial plans may pay slightly above the Medicare rates, while doctors say that many of the new exchange plans are offering rates below that.
Physicians are uncomfortable discussing their rates because of antitrust laws, and insurers say the information is proprietary. But information cobbled together from interviews suggests that if the Medicare pays $90 for an office visit of a complex nature, and a commercial plan pays $100 or more, some exchange plans are offering $60 to $70. Doctors say the insurers have not always clearly spelled out the proposed rate reductions.
Some experts minimized the impact of lower pay rates on enrollees.
People âmay experience wait times to get in, but that is not unique to people in exchange plans,â said Sara Rosenbaum, a professor of health law and policy at George Washington University,
Rosenbaum said she was not overly concerned about physiciansâ compensation. âI donât mean to suggest that physicians donât deserve to do well,â she said. âBut physicians are very well-compensated people, no matter what.â
Confusion About Rates, Provider Lists
Many doctors say they have not decided if they will participate in the new plans âin some cases, even when an insurer is including them in their provider list.
A survey by The Medical Society of the State of New York found that 40 percent of more than 400 physicians who had responded so far said they chose not to participate in a health insurerâs exchange plan, and one-third said they did not know whether they were participating or not.
Two-thirds indicated they had received no information about reimbursements; of those who did ge that information, âa significant majority indicated that the reimbursement generally was well below what the insurer pays in other contracts,â according to a statement from the societyâs president Dr. Sam Unterricht.
âI have patients calling my office and saying ⌠âOh good, I see youâre in the network,ââ said Patricia McLaughlin, an ophthalmologist in New York City. But, she added, âIâm not sure I am or am not at this point.â
Some insurers have contractual arrangements with physicians that allow them to automatically include doctors in a new plan, unless the physician requests to opt out in writing, according to Mike Scribner, CEO of Strategic Healthcare Partners, a health care consulting firm based in Savannah, Ga., that represents about 700 physicians and 30 managed care hospitals in the state.
Doctors say the Blue Cross Blue Shield Association plans have generally been more straightforward about the discounted rates --and some doctors who had the opportunity to âopt outâ of their exchange plans did so.
Dr. Richard E. Thorp, an internist who is president of the California Medical Association and heads a physician-owned multi-specialty primary care group in Paradise, Calif., said one plan sold on that exchange âwas going to pay us significantly less for doing that business. And we are already very busy.â
His practice delayed signing a contract, he said. But about three weeks ago, the group was informed the insurer was short on physicians and was therefore including doctors from other plans at their old rates. So his practice was included at the higher rate.
Advocates say that consumers should be wary of information in plan directories and confirm participation with their doctors.
The California Medical Association is so concerned about errors that it has asked Covered California, the stateâs insurance marketplace, to remove a search function that lets buyers plug in the names of physicians and get a list of all the plans that they participate in, said Lisa Folberg, vice president for medical and regulatory policy for the California Medical Association.
âThere shouldnât be any ambiguity about whoâs in the network,â said Lynn Quincy, a senior analyst with Consumers Union, the policy division of Consumer Reports.
âThese consumers are buying a product, one dimension of which is to provide a networkâa very important dimension.â
November 28, 2013
Medicaid Growth Could Aggravate Doctor Shortage
By HYPERLINK âAbby Goodnough - The New York Timesâ \o âMore Articles by ABBY GOODNOUGHâ ABBY GOODNOUGH
SAN DIEGO â Dr. Ted Mazer is one of the few ear, nose and throat specialists in this region who treat low-income people on Medicaid, so many of his patients travel long distances to see him.
But now, as Californiaâs Medicaid program is preparing for a major expansion under President Obamaâs health care law, Dr. Mazer says he cannot accept additional patients under the government insurance program for a simple reason: It does not pay enough.
âItâs a bad situation that is likely to be made worse,â he said.
His view is shared by many doctors around the country. Medicaid for years has struggled with a shortage of doctors willing to accept its low reimbursement rates and red tape, forcing many patients to wait for care, particularly from specialists like Dr. Mazer.
Yet in just five weeks, millions of additional Americans will be covered by the program, many of them older people with an array of health problems. The Congressional Budget Office predicts that nine million people will gain coverage through Medicaid next year alone. In many of the 26 states expanding the program, the newly eligible have been flocking to sign up.
Community clinics, which typically provide primary but not specialty care, have expanded and hired more medical staff members to meet the anticipated wave of new patients. And managed-care companies are recruiting doctors, nurse practitioners and other professionals into their networks, sometimes offering higher pay if they improve care while keeping costs down. But it is far from clear that the demand can be met, experts say.
In California, with the nationâs largest Medicaid population, many doctors say they are already overwhelmed and are unable to take on more low-income patients. Dr. Hector Flores, a primary care doctor in East Los Angeles whose practice has 26,000 patients, more than a third of whom are on Medicaid, said he could accommodate an additional 1,000 Medicaid patients at most.
âThere could easily be 10,000 patients looking for us, and weâre just not going to be able to serve them,â said Dr. Flores, who is also the chairman of the family medicine department at White Memorial Medical Center in Los Angeles.
California officials say they are confident that access will not be an issue. But the state is expecting to add as many as two million people to its Medicaid rolls over the next two years â far more than any other state. They will be joining more than seven million people who are already in the program here. One million of the newly eligible will probably be enrolled by July 2014, said Mari Cantwell, an official with the stateâs Department of Health Care Services.
On top of that, only about 57 percent of doctors in California accept new Medicaid patients, according to HYPERLINK âhttp://content.healthaffairs.org/content/31/8/1673.abstractâ a study published last year in the journal Health Affairs â the second-lowest rate in the nation after New Jersey. Payment rates for Medicaid, known in California as Medi-Cal, are also low here compared with most states, and are being cut by an additional 10 percent in some cases just as the expansion begins.
âThe symbolism is horrible,â said Lisa Folberg, a vice president of the California Medical Association.
The health care law seeks to diminish any access problem by allowing for a two-year increase in the Medicaid payment rate for primary care doctors, set to expire at the end of 2014. The average increase is 73 percent, bringing Medicaid rates to the level of Medicare rates for these doctors.
But states have been slow to put the pay increase into effect, experts say, and because of the delay and the fact that the increase is temporary, fewer doctors than hoped have joined the ranks of those accepting Medicaid patients.
âThereâs been a lot of confusion and a really slow rollout,â Ms. Folberg said, âwhich unfortunately mitigated some of the positive effects.â
Adding to the expansion of the Medicaid rolls is a phenomenon that experts are calling the âwoodwork effect,â in which people who had been eligible for Medicaid even before the Affordable Care Act are enrolling now because they have learned about the program through publicity about the new law. As a result, Medicaid rolls are growing even in states like Florida and Texas that are not expanding the program under the law.
Managed-care companies that serve the Medicaid population here through contracts with the state are still hustling to recruit more doctors and other providers to treat the new enrollees.
Molina Healthcare, which provides coverage to Medicaid patients in California and nine other states, has hired more than 2,000 people over the last year, said Dr. J. Mario Molina, the companyâs chief executive. They include not just doctors, he said, but nurses, case managers and call center workers to help new Medicaid enrollees who may be confused about âwhere to go or what to do or how to access health care.â
Dr. Molina said the temporary rate increase for primary care doctors had helped his company recruit them to its networks. Recruiting specialists has been harder, he said, adding, âRheumatology is difficult; neurosurgery is difficult; orthopedic surgery is difficult.â
Ms. Cantwell of the Department of Health Care Services said federal and state rules assured âgeographic and timely accessâ for Medicaid patients, and the state closely monitors managed-care plan networks to make sure they include enough doctors. In California, she said, some 600,000 of the people entering Medicaid in January have already been assigned primary care doctors through an interim health care program for low-income residents that will end next month.
She also said that since the expansion population will be older on average than current adult Medicaid beneficiaries â until now, most adults who qualified were pregnant women or parents of young children â the state had decided to pay doctors a rate âsomewhere in between that for our regular adult population and our disabled adult populationâ for their care.
Dr. Paul Urrea, an ophthalmologist in Monterey Park, said he was skeptical of âblue-sky scenariosâ suggesting that all new enrollees would have access to care. âHaving been in the trenches with Medi-Cal patients who have serious eye problems,â he said, âI can tell you itâs very, very hard to get them in to see those specialists.â
Dr. Urrea said that when he recently tried to refer a Medicaid patient with a cornea infection to another eye specialist, he was initially informed that the specialist could not see the patient until February. âAnd this is a potentially blinding condition,â he added.
Dr. Mazer, who leads a committee of the California Medical Association that grapples with Medicaid issues, said the managed-care plans he contracts with âkeep on sending us patients, and right now Iâm scheduled four weeks out.â
Oresta Johnson, 59, who sees Dr. Mazer through the stateâs interim health care program for low-income residents but will switch to Medicaid in January, said she had faced âexcessively longâ waits to see specialists who could treat her degenerative joint disease. Dr. Mazer is monitoring her thyroid gland, she said, and she is hoping she will not have a problem getting back in to see him next spring, when she may need a biopsy.
âI understand thereâs a lot of people who need help,â she said. âBut am I not going to be able to see who I need to see?â
HYPERLINK âhttp://www.buffalonews.com/city-region/medical/doctor-shortage-found-in-wny-upstate-20140403â http://www.buffalonews.com/city-region/medical/doctor-shortage-found-in-wny-upstate-20140403
Doctor shortage found in WNY, upstate By HYPERLINK âmailto:swatson@buffnews.comâ \o âEmail Stephen T. Watsonâ Stephen T. Watson | News Staff Reporter | HYPERLINK âx.comâ \o âFind @buffaloscribe on Twitterâ \t âblankâ @buffaloscribe. Health care facilities in Western New York and across upstate are facing a shortage of doctors, with hospital officials saying itâs particularly challenging to recruit primary care physicians, according to a new survey by a statewide hospitals association.
The physician shortfall has forced hospitals to reduce or eliminate certain services and to transfer patients to other facilities at times when they havenât had the needed specialists in their emergency rooms, according to the survey by the Hospital Association of New York State, or HANYS.
The survey reports that 123 more doctors in this region retired, or moved, than began practicing here last year. Local hospitals also told HANYS that they have openings for 21 primary care physicians on their staffs. It is all part of a bleak health care picture painted for the Buffalo, Rochester and Syracuse areas.
âPrimary care physicians are extremely difficult to recruit, particularly in upstate communities and rural communities,â said Sherry Chorost, director of workforce for the hospital association.
The HANYS 2013 Physician Advocacy Survey, based on responses from health care facilities across the state excluding New York City, found that hospitals and health systems statewide need more than 1,000 additional doctors â 26 percent of them primary care physicians. The surveyâs authors recommend boosting telemedicine initiatives â which would allow specialists to serve far-flung patients â and offering incentives to physicians who agree to pursue less lucrative specialities, such as primary care, or to practice in underserved areas of the state. Since 2008, HANYS has issued an annual report based on a survey of its hospital and health system members, and the latest version raises the alarm on the declining number of doctors choosing to practice across New York and â specifically â a shortage of primary care physicians.
Western New York, where 4,618 physicians were licensed to practice as of January, lost 123 doctors during a 12-month period that ended in September, or about 3 percent of the ranks. That follows a loss of 184 doctors the previous year and 21 doctors the year before that, HANYS reported.
The region isnât alone in bleeding doctors, according to the HANYS survey. The Syracuse area lost 163 doctors last year, for example, while the Rochester area lost 54, among the 1,026 lost statewide â not counting New York City â as fewer young doctors replace their retiring colleagues.
âThe physicians here are aging. And there are more of them who are aging into retirement age than new people are coming in â that has been the problem,â said Dr. Nancy H. Nielsen, a senior associate dean at the University at Buffalo School of Medicine and Biomedical Sciences and a former president of the American Medical Association.
A decline in the physician population can leave hospital emergency rooms short-staffed for certain specialties, the survey found. That has happened at 61 percent of hospitals statewide â and 71 percent in the area north and west of the Hudson Valley.
Itâs harder to attract doctors to the Buffalo area and the rest of upstate, particularly to rural communities, because young doctors want the amenities â and higher reimbursement rates â available in larger cities, experts say. Western New Yorkâs reputation for brutal winter weather also doesnât help.
âI think itâs hard because a lot of people donât want to live in rural communities. Itâs not the life that theyâre looking for, necessarily. Itâs a special person, I think, that wants to work in a rural community,â Chorost said.
By HYPERLINK âmailto:swatson@buffnews.comâ \o âEmail Stephen T. Watsonâ Stephen T. Watson | News Staff Reporter | HYPERLINK âx.comâ \o âFind @buffaloscribe on Twitterâ \t âblankâ @buffaloscribe | HYPERLINK âGoogle Workspace Updates: New community features for Google Chat and an update on Currentsâ \o âFind Stephen T. Watson on Google+â Google+
on April 3, 2014 - 2:19 PM
, updated April 4, 2014 at 12:38 AM
Health care facilities in Western New York and across upstate are facing a shortage of doctors, with hospital officials saying itâs particularly challenging to recruit primary care physicians, according to a new survey by a statewide hospitals association.
The physician shortfall has forced hospitals to reduce or eliminate certain services and to transfer patients to other facilities at times when they havenât had the needed specialists in their emergency rooms, according to the survey by the Hospital Association of New York State, or HANYS.
The survey reports that 123 more doctors in this region retired, or moved, than began practicing here last year. Local hospitals also told HANYS that they have openings for 21 primary care physicians on their staffs. It is all part of a bleak health care picture painted for the Buffalo, Rochester and Syracuse areas.
âPrimary care physicians are extremely difficult to recruit, particularly in upstate communities and rural communities,â said Sherry Chorost, director of workforce for the hospital association.
The HANYS 2013 Physician Advocacy Survey, based on responses from health care facilities across the state excluding New York City, found that hospitals and health systems statewide need more than 1,000 additional doctors â 26 percent of them primary care physicians.
The surveyâs authors recommend boosting telemedicine initiatives â which would allow specialists to serve far-flung patients â and offering incentives to physicians who agree to pursue less lucrative specialities, such as primary care, or to practice in underserved areas of the state.
Since 2008, HANYS has issued an annual report based on a survey of its hospital and health system members, and the latest version raises the alarm on the declining number of doctors choosing to practice across New York and â specifically â a shortage of primary care physicians.
Western New York, where 4,618 physicians were licensed to practice as of January, lost 123 doctors during a 12-month period that ended in September, or about 3 percent of the ranks. That follows a loss of 184 doctors the previous year and 21 doctors the year before that, HANYS reported. [Western New York has 6 Congressional districts (New York 22-27) with an average population of 720,000 per district. Dividing 6 districts into the licensed physician total gives average of 770 physicians per district, or one physician per 935 residents. HYPERLINK âMy Congressional Districtâ My Congressional District The 6 districts have 3 law schools (Syracuse UCL annually admits 196, Cornell 191, Buffalo SUNY 198, and 3 medical schools URSMD annually admits 104, UBSUNY 168, UMU SUNY Syracuse 160 ]
The region isnât alone in bleeding doctors, according to the HANYS survey. The Syracuse area lost 163 doctors last year, for example, while the Rochester area lost 54, among the 1,026 lost statewide â not counting New York City â as fewer young doctors replace their retiring colleagues.
âThe physicians here are aging. And there are more of them who are aging into retirement age than new people are coming in â that has been the problem,â said Dr. Nancy H. Nielsen, a senior associate dean at the University at Buffalo School of Medicine and Biomedical Sciences and a former president of the American Medical Association.
A decline in the physician population can leave hospital emergency rooms short-staffed for certain specialties, the survey found. That has happened at 61 percent of hospitals statewide â and 71 percent in the area north and west of the Hudson Valley.
Itâs harder to attract doctors to the Buffalo area and the rest of upstate, particularly to rural communities, because young doctors want the amenities â and higher reimbursement rates â available in larger cities, experts say. Western New Yorkâs reputation for brutal winter weather also doesnât help.
âI think itâs hard because a lot of people donât want to live in rural communities. Itâs not the life that theyâre looking for, necessarily. Itâs a special person, I think, that wants to work in a rural community,â Chorost said.
Those recent medical school graduates who do decide to practice here generally are from the area or are married to a native, said Nielsen, who added that the new construction and new programs taking shape on the Buffalo Niagara Medical Campus are helping attract doctors here.
âThere are challenges. I will say that, with the rejuvenation of the whole downtown area, weâre going to see very exciting things happening,â she said.
To address the physician shortfall, HANYS recommends expanding the Doctors Across New York, or DANY, program that, as one of its features, forgives up to $150,000 of student loan debt for young physicians who commit to practicing medicine in certain parts of the state for at least five years.
Medical school graduates from the class of 2012 left school with an average student loan debt of $166,750, according to the Association of American Medical Colleges. In the most recent round of the DANY program, 26 young doctors in 2013 received the full, five-year awards, Chorost said.
The HANYS survey also recommends greater use of telemedicine to allow certain specialists to remotely provide a consultation or other medical service to patients in underserved areas of the state.
And the survey highlighted the shrinking pool of primary care physicians as a particular area of concern.
Sixty-three percent of hospital officials surveyed said they donât have enough primary care physicians, or other personnel, to meet their communitiesâ needs.
A key problem is the relatively low compensation for primary care doctors. Doctors who practice family medicine ranked 23rd out of the 25 specialties included in Medscapeâs 2013 Physician Compensation Report.
They earned an average of $178,000 annually â healthy pay, when compared with that of the typical American, but well below the most profitable specialties of orthopedics, at $405,000, or cardiology, at $357,000.
âIf you have a lot of debt you might be more inclined to go into a more lucrative specialty,â Chorost said.
Experts say there also is a lifestyle issue for primary care physicians, who must squeeze in more patients, work longer hours or remain on call for extended periods of time, particularly those who work in rural communities.
That comes on top of the administrative burden for physicians who run their own practices, said Dr. Thomas J. Madejski, a primary care physician in Medina who serves as assistant treasurer of the Medical Society of the State of New York.
âI think residents and medical students, as they go through school, they see how different physicians act and what their life is like, and thatâs not an attractive part,â Madejski said.
To alleviate the primary care gap, the report recommends expanding the Primary Care Services Corps, which repays loans of nurse practitioners and physician assistants willing to work in underserved areas, and creating more Medicare-funded or state-funded residency slots for primary care doctors willing to work in upstate areas that need more physicians.
email: HYPERLINK âmailto:swatson@buffnews.comâ swatson@buffnews.com
The recovering economy has created challenges for medical staff retention with high turnover rates for doctors, physician assistants and nurse practitioners, according to HYPERLINK âhttp://www.amga.org/wcm/AboutAMGA/News/2014/082114.aspxâ a survey by the HYPERLINK âhttp://www.modernhealthcare.com/section/articles?tagID=969â American Medical Group Association and the St. Louis-based Cejka Search recruitment firm.
The physician turnover rate for 2013 was 6.8%, the same as in 2012 and the highest rate seen since the two organizations began the retention survey in 2005.
For 2013, however, a new wrinkle was that âretirementâ was listed as the reason for separation 18% of the time. This represented a 50% increase and the highest level since the survey began.
The high turnover was not unexpected. It was stated in HYPERLINK âhttp://www.amga.org/wcm/News/ASN/wcm/AboutAMGA/News/2013/648.aspxâ the news release announcing last yearâs surveyâs results that âmedical groups do not expect relief in turnover in the coming year.â
It was also noted that the 2012 rate tracked with improved housing and stock prices. Previously depressed home and investment values had kept doctors from either moving or retiring. The recession had led to only a 5.9% turnover rate in 2009. It was more than 6.4% in 2005, the first year the AMGA and Cejka began collecting retention data, and 6.5% in 2011.
While the turnover rate for physician assistants and nurse practitioners was higher than the rate for doctors, it also was lower than the previous two years. The survey found that advanced practice clinicians had a turnover rate of 9.4% in 2013 compared to 2012 and 2011 when the rate was roughly 11.6%.
Donald Fisher, AMGAâs president since 1980, noted in the release that the surveys âprovide evidence that recruitment and retention continue to be major challenges for health systems.â
The improving economy may present a different challenge for Fisher, however. He may need to find a new response when people ask him about retirement plans.
HYPERLINK âhttp://www.modernhealthcare.com/article/20090622/MODERNPHYSICIAN/306219997â Since 2009, Fisher, 68, who was HYPERLINK âhttp://www.modernhealthcare.com/section/100-most-influential-2014?date=20140819&id=3194785&module=201â No. 59 on Modern Healthcareâs 100 Most Influential People in Healthcare list, has joked that he canât retire, because his 401(k) was now a 101(k). He may need to update that line.
Follow Andis Robeznieks on Twitter: HYPERLINK âx.comâ @MHARobeznieks
