Affordable Care for Children: One Pediatricians’ Experience

Covering children until they are 26 years old, not excluding patients for pre-existing conditions and expansion of Medicaid coverage for all are three tremendous improvements to healthcare over the last 5 years.   However, the hurdles have been numerous.  Many independent private practices like ours are closing because they cannot make ends meet.  More physicians are retiring early and as a result the shortage of primary care physicians is growing. After reading Dr. Sharon Jellinek's article, I realize we are not alone in our financial struggle to stay afloat.  What has changed?

Below are three experiences in this new era of “affordable care” showing there is plenty of room for improvement. 

1.       “You have been excluded from the Health Care Exchange plan because you have privileges at Children’s Hospital.”  Huh?

I was not listed on the health care plan they purchased because I was on the medical staff at The Children’s Hospital.  This fact was not clear when they signed up online.  This did not make any sense.  Why would an insurance plan exclude a community pediatrician who was on staff at one of the top Pediatric Hospitals in the country?  It was so surprising, our small local newspaper covered the story too. 

The liaison at the insurance company confirmed the information was true.  Only pediatricians NOT on staff at The Children’s Hospital were considered ‘in-network’ on two plans designed to save consumers money.  At what cost? “What happens if a child is diagnosed with leukemia and pediatric specialty care?”  The liaison answered the family would be responsible for payment if this rare event occurred.  Talk about reading the fine print!  “Leukemia is not that common, after all”, she said.  Let’s hope not ma’am. 

2.      “I am sorry; a prior authorization is required to order a chest x-ray on your patient.” 

A sick 2 year old girl was sitting in front of me with a 3 day history of fever to 104 degrees.  She had been coughing and had crackles in her lungs.  Ordering a chest x-ray to confirm diagnosis of pneumonia has been standard of care for the past 60 years.  Cost of an x-ray is approximately $50.  Obtaining prior authorizations for MRI or CT scans is common, but a chest x-ray?  Do you know how long a prior authorization for Medicaid insurance takes?  More than an hour on the phone and approval is not guaranteed. I was forced to refer them to the ER for care. The final diagnosis was indeed pneumonia and the ER bill was over $5000. My bill would have been $100 + the cost of chest x-ray.  Affordable care, for whom exactly? 

3.      “The family did not to pay their insurance premium, so the company is taking back $3000.” 

The most dreadful part of Affordable Care are the “take-backs.”  Exchange health plans offer a 90 day ‘grace period’ for patients to pay premiums or terminate coverage.  During this period, they see their doctor and we are paid for care we provide.  Three months to 2 years later, we receive notice the patients did not pay their premiums and insurance will take back thousands of dollars already paid to us for care.  They deduct the money from funds they owe us for other patients to make up the difference.  You would think that is illegal? No, it is big business.  We are forced to bill the families directly and rarely receive reimbursement. 

Is there any other occupation where you go to work, were paid for your labor, used those funds to buy groceries, pay your mortgage, childcare bills, and student loan payments, then without warning, 3 months to 2 years later, that money is taken out of your next paycheck?  

Compensation at the “Big 5” ranged from $10.1 million for Humana’s CEO to more than $66 million for the CEO of United Healthcare in 2015. CEO compensation for Anthem, Aetna, and Cigna also fell within that range.  Affordable health care has definitely helped people.  But who exactly are we trying to help? I am not convinced it is the children growing up in America today. 

The biggest dilemma is the anticipated shortfall of primary care physicians in the future; estimated to be 90,000 by 2020 by the Association of Medical Colleges.  I have four children sleeping in one bedroom and drive a five year old minivan.  I live comfortably and have no complaints.  What concerns me most is whether or not this lifestyle will entice bright, altruistic young people to become physicians in the future? Or will they become CEO’s of health insurance companies or hospitals instead?  I am afraid of the answer.  EVERY child, no matter their age, race, or medical condition deserves access to quality health care.  Who will be left standing to provide it?