When Doctors Stop Taking Insurance
Tim Bower Private health insurance used to be the ticket to a doctor's appointment. But that's no longer the case in some affluent metropolitan enclaves, where many physicians no longer accept insurance and require upfront payment from patients — cash, checks and credit cards accepted.
On Manhattan's Upper East Side, it's not unusual for a pregnant woman to pay $13,000 out of pocket in advance for childbirth and prenatal care to a physician who does not participate in any health plan. Some gynecologists are charging $650 for an annual checkup. And for pediatricians who shun insurance, parents on the Upper East Side are shelling out $150 to $250 whenever a child falls or runs a high fever.
Efforts by insurers to rein in health care costs by holding down physician fees — especially for primary care doctors, who play a critical role in health care though they are among the lowest paid doctors — appear to be accelerating the trend, and some patients say it's getting harder to find an in-network physician.
Orlene Paxson, 33, a stay-at-home mom on Manhattan's Upper East Side, was unable to find an obstetrician she liked who would accept her insurance. Many were not accepting new patients, and one highly recommended doctor did not return her call for five days and did not want to see her until 12 weeks into the pregnancy. It was Mrs. Paxson's first pregnancy and she did not want to wait, so even though her policy does not cover any out-of-network services, she and her husband chose a doctor who doesn't take insurance and paid the entire $13,000 fee themselves.
Once their daughter was born 20 months ago, Mrs. Paxson needed a pediatrician but could not find one who was in her plan, accepting new patients and within walking distance. So she again chose an out-of-network doctor.
"We stayed with her for a year and a half because we loved her," Mrs. Paxson said. At her first scheduled visit after the baby was born, the doctor "talked to me for almost three hours. She knew it was our first baby."
But three months ago, Mrs. Paxson switched to an in-network pediatrician, largely because of the cost of the vaccines. "They didn't cover a dime of it," Mrs. Paxson said of her insurance, adding that she was not complaining. "I made informed decisions."
Though data on private practices is scanty, a new survey of 13,575 doctors from around the country by The Physicians Foundation found that over the next one to three years, more than 50 percent plan to take steps that reduce patient access to their services, and nearly 7 percent plan to switch to cash-only or concierge practices, in which patients pay an annual fee or retainer in addition to other fees.
When doctors stop taking regular insurance or drop a health plan, patients are free to take their business elsewhere. If they have health plans that cover out-of-network expenses, these patients may be reimbursed for fees they pay in cash, but probably not for the entire sum.
The cash-upfront trend raises an uncomfortable question. Can the Affordable Care Act, intended to widen access to health care, succeed by expanding insurance coverage if primary-care doctors are walking away from insurance?
"If all it means is that doctors who serve the wealthy are figuring out ways to avoid the hassles of insurance, I'm not sure it's a public policy problem," said Marsha Gold, a senior fellow at Mathematica Policy Research in Washington and an expert on health care financing. "The real problem comes in if it really restricts the choices people have and makes it worse than it is now. We don't really have the data to know."
The country is already facing a shortage of physicians, according to the Association of American Medical Colleges. By 2025, the nation will have 100,000 fewer doctors than needed, according to the association. With fewer medical students choosing to go into primary care, shortages in this area are expected to become especially acute.
Physicians are increasingly feeling shortchanged by insurance companies, said Dr. Bob Hughes, an otolaryngologist in Saratoga Springs who is president of the Medical Society of the State of New York. "Insurance companies do not negotiate with physicians. It's all take-it-or-leave-it contracts," he said.
A June report by the Medicare Payment Advisory Commission, which advises Congress and focuses primarily on the government plan for seniors, suggests adults ages 50 to 64 are having more trouble getting an appointment with a new physician. Some 30 percent of privately insured individuals who were looking for a new primary care doctor in 2011 reported problems finding one, compared with 26 percent in 2008. (Only 14 percent had a problem finding a specialist in 2011.)
Cash-only practices may exacerbate the access problem. Since her doctor stopped accepting her insurance, Kathryn Vanasek, 43, a mother of two in Manhattan, hasn't been back for a checkup or preventive screenings, relying on a new walk-in clinic for urgent problems like an ear infection.
Her annual physical would cost at least $250 out of pocket, Ms. Vanasek said, but she would not get any money back from her insurer until she met the deductible.
"You are making a decision between preventive medicine and reactive medicine," she said.
If you choose to see a physician who will not accept insurance, experts advise a few precautions:
¶Read the fine print on your health insurance policy. Though many plans provide out-of-network coverage, the reimbursement may cover only a fraction of your costs.
¶Try to estimate your out-of-pocket costs in advance so you can pay the physician with money saved in a flexible spending account, which is sheltered from taxes.
¶Ask yourself whether you really must see a doctor who does not take insurance. Is the care really better? Ask acquaintances outside your regular circle for references. If you are willing to travel, you may find a highly recommended physician who takes your insurance.
¶Keep track of your expenses and receipts, file out-of-network claims promptly and keep copies for yourself. Call your insurer to follow up; it is not unusual for an insurance company to lose paperwork.
¶Watch for expenses that will not be reimbursed. Children's vaccines, for instance, may not be reimbursed even if you have out-of-network coverage. The global fee quoted by an obstetrician for childbirth should encompass all care required unless you have complications, need to see another specialist or require a last-minute Caesarean section.
¶Doctors who don't take insurance are likely to refer to others who don't. Make every effort to ensure that expensive services, such as hospitalizations and surgery, are with network providers and that you have the required approvals from your insurer.
A version of this article appeared in print on 10/02/2012, on page D5 of the NewYork edition with the headline: A Possible Price to Pay if Doctors Spurn Insurance.
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