Congress needs to adopt my new rules for health care providers right away.
- If you take Medicare reimbursements, you take Affordable Care Act policy reimbursements.
- If you take CMS grants for Accountable Care Organizations, you take Affordable Care Act policy coverage.
- And if you take reimbursements from the same insurers who offer coverage on the exchange, you take Affordable Care Act reimbursements.
Did you think those rules were already in effect? Because I certainly did, at least until today.
Just when you think it's safe to breathe
We've had the same doctor for 20 years. On August 1st his individual practice merged into Regal Medical Group, a large, multi-area medical group. Regal Medical Group is an Independent Practice (or Physician) Association, or a group of individual doctors who combine their practices into one large group.
No problem, we thought. Sure, they're located farther away, but it's not terrible. Worth the extra time driving to keep a doctor who knows us and knows our history. But we just discovered how wrong we were.
I've written in the past about our son's ongoing health issues. Last year, he signed up for Covered California and bought the Platinum plan through Blue Shield. It's expensive for a 25-year old, but he wisely decided it was worth paying extra for the peace of mind he would get from knowing he'd have deductible-free coverage for his health issues. His doctor was in the network, so all was good.
Until the merger. This week, he had a flareup on the diabetes management side of things and so he called the doctor and made a sort-of-emergency appointment. He showed up for the appointment this morning, presented his insurance card and was told they don't take any insurance under Covered California.
I couldn't quite believe the text I saw from him. Blue Shield policies are exactly the same from a coverage and deductible standpoint, whether purchased on the exchange or not. Regal Medical Group accepts Blue Shield coverage for employers and other sponsors, including Medicare.
They just don't take coverage under the ACA.
Why the hell not?
Bear with me for a minute while I climb into the weeds. At first glance, Regal appears to be its own self-contained HMO. I could possibly understand a standalone HMO refusing to take insurer reimbursements from Covered California if that was their structure. But then I saw this page where they list the insurers they "work closely with."
And then I did a search at Blue Shield on providers under all plans. Guess who I found?
Well, whaddya know? They do take Blue Shield reimbursements. Just not for Covered California plans. But hey, Medicare and Medicaid is just fine with them. One Regal doctor even has this on his website:
In response to inquiries about the Affordable Care Act (Obamacare), Pacific Coast Urology Medical Center advises our patients that we will NOT participate in any healthcare exchanges. If you join an exchange we will forward your medical records to a urologist of your choice after receipt of an appropriate release form and fee. Should you wish to continue to be seen by Dr. Pugach after joining an exchange you may do so by paying our fee-for-service rates.
A shorter version: "F*ck you if you have Obamacare." Lest we forget, of the entire universe of insureds in this state, only about 7 percent are covered by individual policies purchased on the exchanges, in this case, Covered California. Let that sink in. To those of us who can't buy insurance without buying it on the exchange, a large middle finger is thrust in our faces.
What spiteful, nasty people. I suppose it relates to the fact that reimbursement rates on Covered California policies are intended to bend the cost curve downward, so they are about 30 percent less than rates for commercial coverage.
We've seen this in other states, but it's been contained inside of the insurer's networks, so that the networks offered are limited to those doctors and providers who agree to the insurer's terms and conditions without nasty, rude statements on doctors' websites.
In California, providers who accepted reimbursements from insurers under standard plans were also included in the Covered California networks at the default reimbursement rate. The assumption, which should have been a correct one, was that if they were taking reimbursements under employer-provided plans, Medicare and Medicaid plans, they would accept them under Covered California. Also, providers have a 45-day window to renegotiate or terminate any contracts they wish before those reimbursement rates are locked in. Evidently, this has invited doctors to negotiate terms where they take reimbursements from the same insurer for plans other than Covered California plans.
CMS Grants, yes. Obamacare, no. WTF.
There seems to be no issue with accepting Medicare and Medicaid patients. Or grant money, for that matter. Just Obamacare.
Regal has an affiliated organization called the Heritage Provider Network, which receives grant funds from CMS for implementation of an Accountable Care Organization. ACOs are organizations authorized under the ACA to experiment with new ways to deliver outcomes-based health care. From their brochure:
HPN continues to be at the forefront of healthcare change by focusing on the impact of the recent healthcare reform legislation, including the implementation of Accountable Care Organizations. Because HPN has been providing quality, affordable “accountable” care as a delegated medical group for over 30 years, it is extremely well-positioned to influence policy and successfully lead the next evolution in healthcare.
They receive federal grants to develop new models of delivering care, which is how they appear to be approaching Medicare recipients. I loved this hearts and flowers description of their specialized care from a recent newsletter:
On October 13, 2013, Heritage Provider Network was mentioned on The New York Times website for the Heritage California ACO’s preventive focused beneficiary engagement activities. In an article called Obamacare: The Rest of the Story, Bill Keller mentions Heritage California ACO as a positive example of how ACOs are focused on the treatment of patients, not diseases. “The Heritage Provider Network, a huge accountable care organization in California, offers Medicare patients free dance lessons, healthy cooking classes and casino excursions that feature “brain power” activities on the bus.”
According to Mr. Keller, Heritage California ACO has embraced the entrepreneurial energy that is fueling what he calls the Silicon Valley of preventive care.
Ooooo. Free dance lessons, healthy cooking classes and casinos! Screw you, under 65ers, because we're getting federal funds to head off to casinos while doing brain power activities.
And all at federal expense.
Heritage California ACO (HCACO), an affiliate of Heritage Provider Network (HPN), has been selected to participate in the Pioneer Accountable Care Organization (ACO) model, a transformative new initiative sponsored by the Centers for Medicare & Medicaid Services (CMS) Innovation Center.
Through the Pioneer ACO Model, HCACO will work with CMS to provide Medicare beneficiaries with higher quality care, while reducing growth in Medicare expenditures through enhanced care coordination.
Just don't let any of the Obamacare riff-raff through the door.
These rules need to happen now
So again, these are my rules and they ought to be federal rules. If you take Medicaid and Medicare money, you take ACA coverage. If you take grants, you take ACA coverage. If you accept coverage from an insurer under other plans, you accept it under the ACA.
As for me, it's disappointing to discover that our trusted physician has chosen an organization like this one to partner with. I'm sympathetic to the challenges of private practice and understand why joining a group like this is attractive. But there are other groups in this area who not only are fairly large groups, but who also accept reimbursements under the Affordable Care Act. I can only assume his decision was made as a statement against patients like us, who had coverage for years until we didn't, who paid cash when we had no coverage, and who always relied upon his medical expertise and bedside manner.
It makes me sad, but we'll find another primary care doctor. Anyone who refuses ACA coverage out of spite must have forgotten their Hippocratic oath.
Mostly though, it makes me mad. Because this is preventable on so many levels. If Republicans would quit whining about it and allow some corrections to it, we could all be better off.
Regal Medical Group, by the way, is a for-profit concern. Their arrogance in this situation is enough to make me want to spread the word far and wide that greed is no substitute for compassion, particularly when their patients can pay.