If you thought you were getting the raw end of the deal because your insurance plan's copay shot up by a few bucks or you can no longer afford brand-name meds, it may be time to quit whining. Does your favorite doc still take your insurance plan? If so, count yourself lucky. Due to a contract dispute between providers and United Healthcare, as of last week, thousands of East Bay residents covered under the carrier's preferred-provider plans will have to find new physicians or fork over out-of-network fees.
Doctors bickering with insurance companies is hardly new, but many are claiming the latest contract offered by United Healthcare, which merged last November with PacifiCare in an $8 billion deal, is downright insulting. The California Medical Association analyzed the document back in April and kicked a memo to the state Department of Managed Health Care highlighting dozens of points of contention, including many it claims violate state laws governing health plans. The department, in turn, notified the carrier of its concerns and gave it ten days to make modifications. Aileen Wetzel, associate director of the CMA's Center for Economic Services, says that United Healthcare has yet to spell out any changes it intends to make.
Yet it wasn't the alleged rule-breaking, but the slashed fee schedule that has doctors in a tizzy. In some cases, United will now reimburse providers more than 40 percent less than it paid out previously. So scores of them are doing what locals know how to do best: They're protesting, by refusing to sign.
Dr. Ralph Berberich is among them. His four-member practice at the Pediatric Medical Group in Berkeley had two reactions, he says: horror and dismay. But he's no longer surprised by insurance companies' cost-cutting antics. Seems the classic medical care model, emphasizing the doctor-patient relationship, is kaput. "Insurance companies own the patients and move them around at will," he laments. "They no longer belong to us."
Still, Berberich expects that he'll continue treating the roughly 15 percent of his patients affected by the change, even though their payments to him will more than double. But it's not necessarily because they're deeply devoted, or loaded. "Most have no place else to go," he says. "As far as I know, there's only one other pediatric group in the area that has managed to take this insurance."
United Healthcare spokesman Tyler Mason refutes the notion that most doctors are unhappy with the deal on the table. According to him, contracting is going "extremely well" and 95 percent of providers have given their seal of approval. "There are some physicians out there that we're still negotiating with," he allows. "But when all is said and done, there will be minimal disruptions for members."
Mason's suggestion to doctors who claim they can't afford to accept the new terms? Do a reality check. "The physician down the street from them is accepting our contract," he says. "We look at market rates, and that's what we're charging." The company's expected end result? 98 percent compliance. But Berberich and other local doctors dismiss that figure as wishful thinking. "I sincerely doubt that's the case," says Wetzel, who has fielded dozens of calls from doctors outraged at the rate cuts. "Not many physicians can cover that overhead."
Dr. Steven Una has a slightly more blunt response to Tyler's estimate: "That's baloney." He runs a practice in Castro Valley and serves as president of Bay Area Preferred Physicians, a nonprofit that helps physicians understand and execute contracts with preferred-provider organizations. Getting local doctors to agree has been so rough, Una says, that United sent managers door-to-door in an attempt to rope doctors into signing. But the reps didn't quite get the reception they expected.
"California's different from the rest of the country," Una explains. Solo practitioners here have grown savvy and formed independent associations or nonprofits like the one he heads up. "It gives them the ability to contract on equal footing with larger groups and foundations. Because quite honestly, what often happens is that individual physicians get whacked big time." And at times like this, even sizable organizations can feel as if they're being steamrolled. Dr. Len Kutnik, who represents more than three hundred pediatricians as director of Children First Medical Group at Children's Hospital in Oakland, says United Healthcare has been "amazingly unresponsive" to the groups' efforts to negotiate. "It feels very much like a powerful insurance company trying to do a power play by pushing people into accepting the model they want to push them into," he says. "I would've thought as a new healthcare company coming in, United Health would've wanted to generate goodwill among patients and providers. Instead, they're creating ill will."
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