News

ER system suffers as HMOs maximize their profits

As any recent visitor can tell you, the emergency care system in California is failing. Sixty-seven hospital emergency departments have closed in California in the last 10 years, and more closures are threatened. Patient visits to ERs have increased during this time by 20 percent. The number of Californians without health insurance is rising, and the number of MediCal recipients has skyrocketed. Although MediCal provider fees have not gone up in five years, the state has "promised" a 10 percent cut to providers that will force more patients into overcrowded ERs and shove the system closer to financial collapse. ER patients already wait for hours to be seen, and admitted patients languish in ER hallways for hours or days since there are no vacancies upstairs for more inpatients. Specialists have fled ER call panels in droves, and patients are frequently transferred to other cities in order to get specialty consultation.

The public believes emergency medical care is a right but has failed to adequately fund the emergency care system. The crisis in emergency care is not restricted to urban hospitals in low-income neighborhoods; it affects every emergency department in every community in the state. When the system lacks capacity and specialists are scarce, your insurance card will do nothing to insulate you from the problem.

HMO patients believe that if they pay their premiums and go to network hospitals, they should not receive a "balance bill." Emergency physicians agree totally with our patients. If HMOs would pay physicians for emergency care already provided to their enrollees, patients would never receive such bills. HMOs could prevent balance bills by maintaining a full network of specialty physicians at network hospitals and by contracting with hospital physicians at reasonable rates, however, the plans have chosen to reduce their costs by free-riding on emergency providers and then shifting a portion of the costs unto enrollees. The Department of Managed Health Care, if not actually complicit in this cost-shifting, has certainly created a permissive environment and in the past three years has introduced a series of extralegal regulations that if ever enacted would wreak havoc on the emergency care safety net. Kaiser, the largest HMO in California, manages to pay physicians fairly while staying in the black and growing its market share. Why can't other HMOs obey California law and provide fair and reasonable reimbursement for emergency care? They could, but their goal is not to protect patients but to maximize their profits. For the HMOs and their minions, the capitated medical groups, shifting part of the cost of care unto patients is part of their business plan.

Big insurance companies transfer billions of dollars in profits each year to out-of-state corporate headquarters and into the pockets of shareholders. The DMHC occasionally slaps the health insurance plans on the wrist with a small fine and trumpets this enforcement action to the press; then the "regulators" look the other way while the HMOs continue to turn malfeasance into profit.
CAL/ACEP represents the emergency physicians in California. We agree to never send another bill to an HMO patient as long as we are guaranteed a fair payment and a quick, inexpensive way to settle billing disputes. All we are asking for is a revenue-neutral solution. We are small businesses, usually just 10 to 20 physicians working together to cover one or two emergency departments. We can't afford to go to court and face a cadre of corporate attorneys every time an HMO underpays us by $100. The average ER physician bill is $360 per visit. The average amount of a balance bill paid by an ER patient to an ER doctor is $30! This data is from a survey of the three largest emergency billing companies in the state, and we have made the results public. Don't be fooled by the bogus so-called "study" spouted by the CAHP that was obtained by automated telephone survey and includes balance bills sent by hospitals, which may run into the thousands of dollars.

The HMOs have not agreed to a revenue-neutral solution. The DMHC wants to take patients out of the middle of billing disputes (good) but proposes regulations that leave ER doctors in the middle with no hope of fair payment. The DMHC has promulgated regulations that would transfer more than $400 million from emergency providers to the plans. ERs would be forced to cut staff leading to even longer patient waits. Many ER doctors in training would leave the state, and the current shortage of ER doctors would get even worse. The already failing system cannot afford to transfer half a billion dollars annually to the HMOs. It's time for the CAHP and the state regulators to live up to their rhetoric, to put patients before profits, to support a proposal for fair payment that is revenue-neutral and not an HMO windfall. It is time to for the regulators to quit fiddling around while the emergency care system burns to the ground.


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