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The Doctor Is Out

The state wants doctors to treat the uninsured, but not enough to pay them a fair wage

Andy Bromage

October 02, 2008

His office is filled with antique eye charts and dark wood examining tables. There's a box of lollipops for the kids on their way out the door.

Once he trudged through a snowstorm in the middle of the night to help deliver a patient's baby. He gives a 20 percent discount to patients paying out of pocket.

Past the blue bucket of toys and the old-fashioned rocking chairs are examining rooms that are warm and charming, not cold and sterile. He's the only primary care doctor in all of rural East Haddam. And he still makes occasional house calls.

Dr. Malcolm Gourlie, 60, a kindly physician with a white beard and woolly eyebrows, is the kind of family doctor you see in Norman Rockwell paintings, the kind you'd want in your network if you were a big insurance company like Aetna. In fact, Gourlie is part of Aetna's network, one of only a handful of doctors signed up to serve low- and middle-income families enrolled in the state's HUSKY and Charter Oak health plans.

There's just one problem: HUSKY and Charter Oak don't pay Gourlie enough to cover his costs. He's actually paying out of his own pocket, and losing money, to see patients because the fee schedule negotiated by Aetna and the state is so pitifully low.

"We're on the floor with a boot to our neck, just in terms of our survival," Gourlie says. "That's how I feel right now."

The number of doctors joining the Charter Oak and re-launched HUSKY health programs is growing, but it's still sparse. Some of the largest hospitals and physician groups in the state have yet to sign up. Many say they'd lose money if they did.

In Middlesex County, the first county to transition to HUSKY under new insurance companies, one insurer has just one pediatrician in its network, while another has just six. Neither has the one hospital in the county. Hanging in the balance is the welfare of 338,000 HUSKY patients and thousands on Charter Oak who may have good health care on paper, but find it impossible to actually get in to see a doctor.

For a state that's home to the insurance capital of the world, Connecticut has a disturbingly high number of uninsured residents, in excess of 300,000. The state's health care crisis is real, and sweeping solutions are in short supply. Gov. Jodi Rell's fix is the Charter Oak Health Plan, which gives adults — aged 19 to 64, regardless of income or medical history — bare-bones insurance for $259 a month or less. Charter Oak is funded with $11 million from the state and expects to serve up to 19,000 people who earn too much to qualify for Medicaid, but too little to afford out-of-pocket insurance. Charter Oak was devised last year and began enrolling new patients on July 1, 2008. Rell wanted to keep the premiums affordable, so she directed HMOs to design a product that would cost no more than $250 a month for bare bones health care.

So far Charter Oak is doing little to ease the health care crisis. While doctors are struggling through low reimbursements, the insurance companies are making out: They have built 11 percent profits into their projections, double the norm.

Even the best-intentioned doctors, like Gourlie, can't afford to participate, casting doubt on whether the state will ever land enough physicians to make the program viable.

This year, the state combined HUSKY, Connecticut's Medicaid program, with the new Charter Oak plan, figuring that only combining the two would produce profits large enough to make running Charter Oak worthwhile for the insurance companies. Three insurance companies were selected to run the programs: one that already served HUSKY patients, and two that did not and had to assemble physician networks from scratch. Building those networks has been a slow and sometimes painful process, as doctors balk at the rock-bottom pay scale. Just last week, Rell's administration requested approval from the feds for a four-month delay to allow time for the state to get more doctors and hospitals to participate in the HUSKY program.

Health care advocates and lawmakers have pushed the Rell administration to slow down or freeze enrollment until enough doctors are in place to handle the expected crush of patients. But the governor is forging ahead, saying that people are already getting services under the new plans and to freeze it now would deny health care to those who need it.

The Gourlies were among the first practices in Middlesex County to sign up for Charter Oak when it was announced. Pam says they wanted to do it because they're "altruistic by nature. We treat people in our community because they are our patients and times are tough for everybody," she says.

Before long the phone was ringing with new Charter Oak patients seeking appointments. The Gourlies, who ordinarily treat patients from East Haddam and contiguous towns, were getting calls from as far away as New London, a 35-mile drive. The Gourlies wanted to help out, but not at the expense of their lifelong patients, so they turned down dozens of requests in those early days.

Dr. Gourlie calls Charter Oak a "really good program" but says it's been awfully disorganized. Information about reimbursement rates, what services were covered, patient IDs and eligibility lists were still unavailable weeks after the programs kicked off. "The information wasn't there and we didn't know where to look," Dr. Gourlie says.

Gourlie grew so frustrated in the programs' opening weeks he drafted a termination letter to Aetna and was ready to bail out, until a company higher-up called him and personally asked him to reconsider. Gourlie's staying in for now, but isn't sure how much longer he can work for no pay.

Gourlie has cared for generations of families in the village of Moodus, a section of East Haddam. Eight thousand people live here and Gourlie is the sole remaining family doctor. A few years ago his practice had three doctors, plus a physician's assistant. The two doctors moved on to other opportunities. The physician's assistant recently left for a job at Hartford Hospital that pays $15,000 more.

The practice is a true mom-and-pop operation: Gourlie sees the patients, his wife Pam runs the office, along with five office assistants. Gourlie's father was a family doctor in Enfield, and Gourlie still uses his father's medical bag and his big wooden desk. Inside his modest office, Gourlie practices a type of medicine that's increasingly rare in today's managed care world: treating a person's soul as much as their symptoms. Under Charter Oak, Gourlie says, that will be hard, if not impossible, to do.

The problem is this: Say a patient comes in for a sprained ankle but during the course of the visit you learn she is depressed or grieving for a lost loved one. Under the old system, the doctor could treat the patient however he saw fit, be it medication, informal counseling, or just talking it through.

Under Charter Oak, mental health has been "carved out" in order to keep the premiums low, meaning it's not covered. Now when a doctor learns a patient is depressed, he must stop the visit, call the insurance company, verify policy details and send the patient out the door to another service.

Depression is alarmingly common in primary care: Gourlie says he writes more prescriptions for depression and anxiety than almost anything else. Prescriptions reflect the patient population. And there aren't enough mental health professionals available to meet the demand for services, Gourlie says. "Carving out basic mental health care is a fundamental failure to understand how primary care works," Gourlie says.

The Rell administration says it needs time to develop doctor networks, but what's really required is money. Plenty of it.

The state's reimbursement rates for HUSKY are so out of date that even doctors who want to participate can't afford to, says Douglas Arnold, executive director of Middlesex Professional Services. Douglas has more than 300 doctors in his health group, but only a handful of them have signed on as HUSKY providers. One of them is Gourlie.

Hospitals all over the state are declining to join Charter Oak: St. Vincent's Medical Center in Bridgeport, Stamford Hospital, Johnson Memorial Hospital in Stafford Springs, Milford Hospital and Griffin Hospital in Derby, to name a few. Windham County still lags far behind, particularly on free-standing providers, those not in a hospital setting. Aetna Better Health has just 13 doctors in all of Windham County, while Americhoice has 25.

To illustrate the payment problem, consider the following scenario: A mom brings her 4-year-old in for a high fever. The attending pediatrician, in most cases, would get $55 for that visit if she's on HUSKY. If she has commercial insurance, he'd be reimbursed closer to $80.

If she's on Charter Oak, the doctor gets considerably less for the routine office visit: just $12.48 if he's a primary care physician and $2.48 if he's a specialist, after co-pays of $25 or $35. Charter Oak puts doctors in charge of collecting co-pays and if they can't collect, they're out the difference. HUSKY, by contrast, has no co-pays, or very few of them.

"People always have a reason they don't have their $25," Dr. Gourlie says. "They have their cigarettes and everything else, but not their co-pay. The doctor's always the last one to get paid."

After leaving the HUSKY fee schedule unchanged for 17 years, the state finally dedicated $57 million this year to raise doctors' pay. That's hardly solved the problem.

"They went from terrible to awful," Arnold says. "They were paying under $30 for an office visit. Now they are up to $37. That's like saying the knife I'm going to cut you with, I'm going to make the blade six inches deep instead of eight inches deep. "There's an easy solution to this," Arnold says. "It's spelled M-O-N-E-Y."

The state needs to raise the rates far higher than they have, Arnold says, but that task is neither easy nor cheap. The state's currently facing a $300 million budget shortfall for next year and potentially more in lost income tax revenue from newly unemployed Wall Street bankers residing in Fairfield County.

It wasn't supposed to work out this way. Charter Oak was supposed to be a win-win-win: a win for doctors who want to provide care to uninsured middle-income families; a win for HMOs, who could earn a little profit while running a cumbersome health care bureaucracy the state isn't equipped to manage; and most importantly a win for the thousands of uninsured in Connecticut, who could now buy no-frills insurance for as little as $259 a month.

Instead, everyone's scrambling to make sure Charter Oak and HUSKY don't fail the vulnerable populations they're designed to help. Doctor participation is improving, but it's hard to tell how meaningfully. An official state report says recruitment's up by 60 percent since June, but many of those doctors are double counted because they've signed up for multiple plans.

HUSKY patients have until Nov. 25 to select from one of the new HMOs or they'll be defaulted into one of them randomly. Sheldon Toubman, the New Haven Legal Assistance Association lawyer who's become a leader in the fight for health care access, fears patients will go into networks without enough doctors. Numbers back up his concern.

In Middlesex County, for example, fully 94 percent of HUSKY enrollees had not selected new HMOs as of Sept. 8. If they were defaulted into Community Health Network of Connecticut, they'd have 161 doctors to choose from. With Aetna or Americhoice, the two new HMOs, the selection is cut in half: 69 and 70 doctors respectively.

"Obviously two of the plans are grossly inadequate in their provider networks, so it is a very troubling picture," Toubman says.

Michael Starkowski, the state commissioner of social services, insists no one will be defaulted into a network that is inadequate, and notes that out-of-network care is available in the interim.

"Providers want to enroll," Starkowski says during a recent interview at his Hartford office. "They all have some questions still. Business questions. On how Charter Oak will work. What rates will be that are eventually negotiated with managed care plans. Can their practices handle another 30 people." Also, the paperwork explaining rate schedules is more than 40 pages long, and doctors need time to go through all that, Starkowski says.

Health care advocates point to all this as evidence that Charter Oak was launched prematurely, before serious details were ironed out. Starkowski doesn't see it that way.

"We brought some things to the governor's office's attention, the governor's office was attentive, made sure we had resources to move the program forward," Starkowski says.

Health care watchdogs have also taken issue with the profits HMOs are earning to administer HUSKY and Charter Oak. At a hearing before the state Medicaid Managed Care Council in Hartford recently, the state's actuaries laid out the convoluted method they use to determine how much managed care companies should get paid, a lesson that seemed to confuse even some of the sharpest health care experts in attendance.

The bottom line: HMOs will take home 11 percent more in 2008-09 than they did in 2007-08, which works out to something like $65 million. A more typical annual increase would be 4 percent.

Part of that's due to what they call "medical trend" increases — new clear braces cost more than the old metal kind, for example. The rest is chalked up to what Connecticut Health Policy Project director Ellen Andrews calls the "fudge factor:" basically that HMOs say, We're not doing this unless you give us this much more.

Starkowski says it's not that simple. "No one ever goes into it saying, I have to try to increase the profit margin of the managed care companies," he says. "We try to cut the best deal for Connecticut, while still providing services."

Doctors, meanwhile, are left to fend for themselves. At a recent meeting with three Middlesex County doctors, including Gourlie, Starkowski told the docs they had the power to negotiate better pay with the insurance companies. True in theory, but a stretch in practice, especially for small practices such as Gourlie's that lack enough doctors to have real bargaining power.

"(Starkowski) didn't understand," says Pam Gourlie, who also attended the meeting. "We have absolutely no power to do that, and we couldn't make him understand that."

The Gourlies will try to stay an Aetna provider, but are exploring alternatives just in case. One of the three HMOs allows you to break off the Charter Oak piece and just serve HUSKY. Recently, they were seriously considering it.

Asked how confident she is that it will work out, Pam says "not very." She's taking it day by day and not making any ultimatums. After all, she says, we're dealing with people's lives.¦

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