Reviewed by James Ives, M.Psych. (Editor) Feb 25 2020
For five years, Rasha Salama has taken her two
children to Dr. Inas Wassef, a pediatrician a few blocks from her home in this
blue-collar town across the bay from New York City.
Salama likes the doctor because Wassef speaks
her native language — Arabic — and has office hours at convenient times for
children.
"She knows my kids, answers the phone, is
open on Saturdays and is everything for me," she said.
But UnitedHealthcare is dropping Wassef — and
hundreds of other doctors in its central and northern New Jersey Medicaid
physician network. The move is forcing thousands of low-income patients such as
Salama to forsake longtime physicians.
Across the nation, business and contractual
disputes are separating patients from longtime doctors. This often occurs when
doctors don't want to accept the rates insurers are willing to pay. It
sometimes occurs when insurers' business plans require having a narrower
network of doctors — doctors whose practice patterns may be easier to control.
But in this case, the cause of the exclusion
goes to even deeper business connections: Wassef and other doctors say the
insurer appears to be trying to shift patients to Riverside Medical Group, a
20-office physicians' practice owned by Optum, a sister company of
UnitedHealthcare, both of which are subsidiaries of UnitedHealth Group.
UnitedHealthcare is essentially forcing patients to transfer to doctors it
controls, the doctors allege.
Indeed, several patients said the health plan
directed them to Riverside when informing them their doctors were being
dropped.
Lawrence
Downs, CEO of the Medical Society of New Jersey, said he estimates
UnitedHealthcare is trying to remove hundreds of doctors in central and
northern New Jersey from its network. That is the same area where Riverside
Medical operates, he noted.
"It seems like they are steering patients
away from small, community-based doctors to large groups that they own,"
he said.
Good for profits
That raises questions about whether this type
of "vertical consolidation" — the term for a practice occurring
across the country — is a strategy that is good for profits but bad for
patients.
UnitedHealthcare said the changes are not part
of a campaign to get as many patients as possible to the Riverside practice. It
points out that it is retaining the community-based doctors, like Wassef, in
its networks to treat its Medicare Advantage and commercial plan members.
But, experts say, traumatic disruptions in
doctor-patient relationships are an inevitable result of ongoing shifts in the
complicated business of U.S. health care.
Facing a rapid consolidation of doctors'
practices and hospital systems — which have hefty negotiating power to demand
high fees — insurers have limited options to control costs and maintain a
positive balance sheet, said Jacob
Wallace, an assistant professor of public health at Yale University.
Medicaid plans are especially affected because, unlike commercial plans or even
Medicare, they can't increase premiums or demand copayments.
"Plans face a challenging landscape to
keep costs down," Wallace said. As a result, health plans have taken other
approaches, including narrowing provider networks and buying their own
physician practices, he said.
But further complicating matters, many
Medicaid and Medicare managed-care programs are contracted out to private,
for-profit insurers such as UnitedHealthcare. They are looking to create
returns for shareholders. With surging enrollment in government programs,
UnitedHealthcare has enjoyed rising profits and a stock price that has
soared tenfold since 2010.
Wassef and about two dozen other physicians
filed a federal lawsuit in September to get reinstated. Wassef, whose
termination is scheduled in May, said the move could seriously affect her
practice because 80% of her patients are insured by UnitedHealthcare.
UnitedHealthcare gained millions of new
customers after the Affordable Care Act led New Jersey and 35 other states and
the District of Columbia to expand Medicaid and states turned to private
insurers to handle the business. Salama and some other UnitedHealthcare
customers said they like their insurance plan because it offers richer benefits
than other Medicaid options and covers the medications they use.
The company operates New Jersey's
second-largest Medicaid health plan, with 418,000 members. (The state
Department of Human Services has blocked UnitedHealthcare from enrolling any
additional Medicaid members, a severe and rare penalty. That move — which is
not related to the termination of doctors' contracts — stems from complaints
related to care management and discharge planning, the health plan's call
center and other issues.)
A company spokesperson acknowledged the health
plan is dropping 2% of its Medicaid doctors, saying the move was designed to
help control costs.
"As health care costs continue to rise,
we are working to mitigate the impact on the customers, states and members we
serve by negotiating with care providers on their behalf to keep reimbursement
rates affordable," the company said in a statement. "We understand
that our members have personal relationships with their doctors and that
network changes can be difficult."
A practice destroyed
New Jersey Medicaid officials refused to
comment on whether they are concerned about UnitedHealthcare's actions. But
patients caught up in the standoff have reason to worry, said Linda Schwimmer,
CEO of the New Jersey Health Care Quality Institute, a
coalition of health plans, providers and a variety of health trade groups.
"Once you have a trusted relationship
with a provider, it means a lot and it goes to the quality [of your care]
because if you are seeing the same providers and you trust them, you are more
likely to take your medication and adhere to whatever care plan you have,"
she said.
Dr. Alexander Salerno, an internist who runs a
17-doctor multispecialty practice in East Orange, New Jersey, another plaintiff
in the lawsuit, is helping lead the court fight. Salerno's main
office is in a three-story, 19th-century house that his father used for his
medical practice in the 1960s. About 40% of his patients are on Medicaid.
Until the dispute began last year, Salerno
advised his patients to sign up for UnitedHealthcare because of its broad array
of benefits, including vision and dental care, and because of the ease in
referring to specialists.
And UnitedHealthcare never complained about
this group's skill. In fact, the group received a $130,000 bonus last year for
its good care to patients. Salerno said Riverside Medical offered to buy his
group practice in 2018, but he declined.
Since UnitedHealthcare announced it would drop
his group from the network, more than 500 of his practices' patients have
already changed doctors to stay with the UnitedHealthcare plan, Salerno said.
"It's not a bad insurance company. It
just seems like they have become greedy trying to control both ends of the
pendulum — wanting to be the payer and provider," Salerno said.
A federal judge ordered the case to be heard
by a neutral arbitrator, which in late November granted an emergency injunction
that will keep Salerno from being removed from UnitedHealthcare's network until
an arbitrator makes a decision on a permanent injunction, which is expected in
March.
But that leaves patients in limbo.
Glorida Rivera, 68, said UnitedHealthcare's
decision to drop Salerno was upsetting because she relied on him to care for
her diabetes, thyroid and heart conditions. She credits Salerno for referring
her to a cardiologist, who put stents in her heart to clear a blockage.
"He knows my whole story, so why do I
have to change?" wondered Rivera. Nonetheless, she is sticking with
UnitedHealthcare.
Velylia McIver, 83, decided in November to
search for another plan so she could stay with Salerno. But it took her more
than a month to get coverage for some medications.
"I feel caught in the middle of all this,
and it's the pits," McIver said.
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This article was reprinted
from khn.org with
permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an
editorially independent news service, is a program of the Kaiser Family
Foundation, a nonpartisan health care policy research organization
unaffiliated with Kaiser Permanente.
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