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 children are three positive changes in healthcare over the last 5 years. However, I have never really discussed the hurdles involved. There are many.

Numerous independent private practices have closed, more physicians are retiring, and the shortage of primary care physicians to care for these “insured” patients is growing by the day. Below are three personal experiences in this new era of “affordable” healthcare showing there is still room for improvement.

1. “You have been excluded from a plan offered on the Health Care Exchange because you have medical staff privileges at Children’s Hospital in Seattle.” Huh?

A patient told me I was not on the health care plan they obtained from the exchange during that first year because I was on the medical staff at Seattle Children’s Hospital. This was not made clear when they signed up for the health plan online. There had to be some mistake; it did not make sense. Why would an insurance plan exclude a community pediatrician who was on staff at one of the top Pediatric Hospitals in the country? Was I being penalized because I was a good pediatrician? The answer was YES and I was not the only one.

Our physician liaison confirmed the information was true. Only pediatricians NOT on staff at Seattle Children’s were in-network under two specific plans to keep costs low. I asked, “What happens if a child is diagnosed with leukemia and requires a pediatric specialist for treatment?” She answered the family would be held responsible to pay for specialized care. Talk about 'hidden' out-of-pocket costs! It almost felt like they were endorsing medical segregation, the concept of “separate, but equal”. EVERY child, no matter their age, race, or medical condition deserves access to quality health care. “Leukemia is not that common, after all”, she said. Let’s hope not.

2. “I am sorry, but you are not authorized to order a chest x-ray on your patient. That would require a prior authorization and 48 hours to process.” What?

A sick 2 year old girl was sitting in front of me with fevers of 104 for 3 days. She had been coughing and had crackles in her lungs on exam (code for possible pneumonia.) It has been standard of care to confirm diagnosis of pneumonia by chest x-ray for the past 60 years. Cost of an x-ray is $50-$100. In 15 years of medical practice, I had waited for approval on expensive MRI or CT scans, but a chest x-ray? That child could not wait 48 hours, so I had referred them to the ER for their chest x-ray. The final diagnosis was indeed pneumonia and the ER bill was $5000. My bill would have been $100 + the cost of chest x-ray. Affordable care, seriously?

3. “The family was unable to pay their insurance premium, so the company is taking back $5000.”

THE worst financial hardship from Affordable Care these days is the “takebacks.” Exchange health plans offer a 90 day grace period in which to pay premiums or drop a patient from coverage. During this period when they see their doctor, we are paid for care we provide. Three months later, we receive notice the patients did not “really” have coverage since they did not pay their premiums. We are notified the insurance will take back $2000-5000 they paid us for care provided and it will be deducted from money they owe us for other patients. You would think that is illegal? NO, it is big business.

Is there any other occupation where you do the work, were paid for that work, used those funds to buy groceries, pay your mortgage, and childcare bills, then without warning, 3 months to 2 years later, that money is taken out of your next paycheck? How can I be certain I can feed my children, pay for my home, and other basic necessities?

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.

As a pediatrician, I have four children sleeping in one bedroom and drive a five year old minivan. I live comfortably, that may even sound extravagant. However, I am not certain this lifestyle will entice more doctors to enter primary care. The Association of Medical Colleges estimates we will be short 90,000 primary care doctors by 2020.

Affordable care has definitely helped insurance companies bottom line. So who exactly are we trying to help? I am not convinced it is the children growing up in America today. Are you?

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