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October 1, 2007

Physician shortage tied to reimbursement rates

Insurance reimbursement often lower here

By JEFF MEYERS

PLATTSBURGH -- On the surface, health insurance seems like a simple concept: The patient provides a health-insurance card to the doctor, and the insurance company takes care of the bill, excluding any patient co-pays.

But as with most anything else in life, insurance coverage is decidedly more complex.

An array of twists and turns throughout the process often goes unnoticed by the patient but can severely impact a North Country physician's ability to operate a business -- and even determine whether a doctor can afford to practice here.

PAYMENT CONCERNS

Physicians establish contracts with insurance companies to determine what kinds of reimbursements they will receive for specific kinds of patient services.

It is not uncommon, however, for insurers to pay considerably less than what it costs the doctor to treat a patient. That is when individual physicians may decide not to accept certain insurance coverage.

"Physicians, in general, like to accept all insurance coverage," said Dr. Wouter Rietsema, director of physicians for CVPH Medical Center. "But in a community like Plattsburgh, where the doctor is a small businessman, sometimes insurance companies' practices are unacceptable."

In larger urban areas, doctors often form partnerships with other physicians, which gives them added clout when negotiating contracts with insurers.

In the North Country, where there has been an alarming decline in the number of practicing physicians, doctors have to go solo against the insurer and can't always negotiate for more amiable reimbursements.

"At some point, the doctor can't justify accepting an insurance that's not meeting his cost of business," Rietsema said. "The typical primary-care provider has an overhead of 60 to 70 percent. In the end, sometimes the doctor has no other choice" than to not accept a particular coverage.

"Patients will think that they have good insurance coverage, but they don't realize their doctor is not getting a reasonable compensation for their services," he added.

When doctors do discontinue relations with a specific insurer, it is with the hopes that that action will force insurers to renegotiate their contract with the physician to provide better reimbursements, Rietsema said.

Doctors can also dispute reimbursements they receive for individual payments. For instance, if they submit a bill to the insurer for a Level 3 service (which pays higher than Level 2) and the insurer only compensates at Level 2, they can collect records to prove that they provided Level 3 coverage.

"The doctor has to expend an extra amount of effort to go that route," Rietsema said. "That could also represent a financial burden."

AREA LOSING DOCTORS

Dr. Richard Webber of Lake City Primary Care has not denied any insurance coverage for his current patients, though he admits that it is difficult to take on new ones with reimbursement that does not pay his office rates.

Although he would not name specific companies, he did say that at least one insurer that many of his patients rely on is notorious for poor reimbursement rates.

"I can't look my patients in the eye and tell them I'm not taking care of them because of an insurer," he said. "But these reimbursements rates have not changed in years. It's getting increasingly difficult to operate a business, and it's a big reason why we can't recruit doctors to the area."

Lake City Primary Care has four physicians -- two full time and two part time -- and two physician assistants. Webber said he would like to expand the business, but doctors are choosing to go to other parts of the country where they can earn a significantly higher salary.

"The doctors who are still here are very dedicated to what they do," he said. "But they're not here for the money. They're here because they love what they do."

He said he didn't know what the answer was to correct the problem but added that it is a horrible situation that is only growing worse.

CVPH Medical Center President Stephens Mundy recently said the physician shortage in the North Country is reaching a critical stage. The ability to go to other areas where reimbursement levels are much more acceptable is one big reason for the downslide.

"Doctors who come here to practice do it for the quality of life, not for the money," Rietsema said. "But they still need to be able to make a reasonable living for what they do."

jmeyers@pressrepublican.com

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