Sunday, December 1, 2013


"I'm sorry," tolls the receptionist in a bored voice, "but your doctor isn't in our plan anymore."

Senator Reid opts out: click on comments at end of this editorial re Reid's Obamacare snub

Item A concerns a doctor whose healthcare policy was abruptly canceled when her own physician announced he was quitting the health care plan, would no longer accept insurance, and would henceforth require monthly "concierge" style payment, plus a cash fee for office visits, and that she'd have to have separate insurance for hospitalization whether needed or not.  As for the healthcare plan he was leaving -- the plan would either be disbanded or taken over by doctors who could speak English.

Note: for the uninitiated, "concierge" style practices require advance payment arrangements such as monthly, quarterly, or annual payments plus fees applicable to the services patients use. Medications are not included. Insurance plans are not accepted.

Item B is about several doctors in various settings who have in common that they've sold their practices to corporate entities, foundations, exchanges, or other business groups. It works like this: the corporate entity buys the practice, then employs the doctor or somebody else to run it on a day-to-day basis. The corporate entity pays the staff, the rent, and the expenses. To recoup its money, and to make more money, the practice is required to double or triple its volume. To accomplish this task, the time spent with  each patient must be reduced, say, to a few minutes. That'll be the job of the staff who now no longer works directly for the doctor or the patient but who instead is responsible to the employer. In this plan, insurance is still accepted, in fact, is welcome. If the on-site managing doctor and his staff can't meet these goals, they'll be replaced.

Healthcare Plans that cover patients, doctors, and insurers vary widely. They may assign doctors to multiple plans and keep track of so-called "production," how many patients each doctor sees and how long the average visit takes. Doctors whose "production" numbers are profitable to  the company will have a higher rate of retention providing they don't rock the corporate boat in other ways (then they're called "disruptive" and get fired anyway).  What procedures and surgeries are allowed will be a corporate decision dependent on cost-benefit ratios, not patient need.

Healthcare Plans may be narrow and include a minimal number of specialists and no highly sub-specialized surgeons. It's your  personal out-of-pocket lookout if services not included in your medical provider network are sought.

Utilization Review (UR) is already used in California for injured workers who may be denied access to specialized care by a UR doctor who is not licensed in California and who has never seen the patient. The UR doctor's judgment may nonetheless overrule the California-licensed primary treating physician's judgment even though the primary physician has spent hours with the patient.

In this way, UR in California and the ACA throughout the USA are joined -- see our previous editorials on the Independent Payment Advisory Board (IPAB) which was originally rejected for Medicare under its previous name, the Independent Medicare Advisory Board (IMAB). Some pundits assert that the ACA under the guise of Obamacare is actually a nationwide watered down HMO and that to keep it that way it's necessary to eliminate as many hospitals and specialized centers as possible, and as many doctors as possible, while making the remaining doctors act like cattle herders trying to avert a stampede.

Stay tuned. These issues have long legs.


"How to practice medicine without a license," San Francisco Chronicle, 8/29/08


  1. I have already been asked if healthcare plans or medical provider networks are obliged to carry a full network of specialists and sub-specialists. The answer is no. That is why subscribers to ACA plans are invited to shop around. Injured workers don't have that choice.

  2. One recurrent question is what could have been done to have averted the Affordable Care Act. The answer is that steps could have been taken by both parties to stop insurance companies from behaving like petty tyrants, e.g, rescinding policies once a subscriber called in sick and imposing annual and/or lifetime limits. That these steps were not taken gave huge deserved impetus to passage of the ACA (Obamacare).

    A new question now concerns Sen. Reid's exempting staff from participation in the ACA. This column has previously discussed this general issue. The answer is that staffers who work for committees as opposed to only for a specific Member of Congress are seen in different legal perspectives: only staffers who work exclusively for a MOC are required to buy Obamacare whereas staffers who are hired by committees are not.

    Whether or not Senator Reid is pushing the limits of the law and stepped over the line remains to be seen. .