By Jean Gunner
SPECIAL TO THE News
Where are our health care premium dollars going? Are we, or our family, or society at risk in the current health care climate? As director of Buffalo Pediatric Associates for 24 years, I have gotten to know and respect other primary care practices and their doctors and providers. I am deeply distressed and concerned by what I see happening.
At this moment, we are in a place of extreme pressure from many sides – the insurance companies, government and patients. As patients, we hold the reasonable expectation that our health care needs will be taken seriously and addressed in a professional, caring, effective and efficient manner.
Over the last decade, insurance companies have been placing more expectations on primary care doctors to provide the best care with optimal results with the greatest efficiency. Insurance companies oftentimes suggest that primary care doctors treat their patients with fewer resources and shrinking payments using convoluted reimbursement formulas. This affects every one of us, because at some point, we all will need our doctor.
Yet with all of the premium dollars that individuals, employers and the government pay, primary care providers are finding themselves this year with lower than average reimbursements from insurance companies to provide services for our patients, and the need to decrease expenses and lay off personnel. In light of the national health care debate, we must be aware of what is actually happening now, so we have a handle on what is being debated and decided upon for our collective health care future.
Primary care doctors and providers are specialists who provide essential medical services. Consulting specialists, emergency departments and urgent care clinics are important and serve their purpose, but they are not our medical home.
Pediatricians fall under a subset of health care providers called primary care. We are specialists who train extensively to provide care to children in a pediatric patient-centered medical home.
A home is necessary for our well-being, and so is a medical home. It is a home to visit when we or our children are not feeling well, and to receive critical development assessment and preventive care during the first stages of life and beyond.
Neither pediatric nor other primary care physicians are being adequately supported by insurance companies. These are the same companies that take in all of our health care premium dollars, either through employer-offered plans, individual plans or the marketplace. Our dollars are going somewhere, but they are not going to sufficiently support our medical homes. And if the home is not supported, it goes into disrepair and falls apart. If our medical homes fall apart, where will we turn for our health care?
Many of us are paying exorbitant insurance premiums. Many businesses are covering larger health insurance premiums for their employees. We are entirely dependent on the health insurance payers, both commercial and public, to care for their members and cover their health care services, such as preventive well checks, immunizations, acute sick care, management of chronic illness and conditions, as well as mental health, substance abuse, care for newborns and their moms, as well as many other critical care services. We have made a compact and contractual agreement to receive compensation for health care services rendered.
The American people, as members of a caring, sane and intelligent society, are entitled to health care as a right. All of this is happening, ironically, in the heat of a political debate to repeal the Affordable Care Act, take away pre-existing condition protection (half of Americans have some pre-existing condition) and give more power to insurance companies.
Prior to the move toward health maintenance organizations (HMOs) in the 1980s, insurance companies for decades were coached on how not to pay insurance claims for medical care.
We are now in a new era of insurance reimbursement: value-based reimbursement. For some insurance companies and government officials, it seems the only value is to withhold care for the people and increase insurance profit at the expense of the health of our nation. We could benefit from less greed and more care!
This value-based system sets up metrics that primary care doctors have to meet, including: controlling overall cost of care, decreasing ER/urgent care utilization, reining in pharmacy costs and specialist care costs, opening access, but not bringing in too many sick patients, and instead using the phone to coach and treat patients. Is this what we want for our sick child or our ailing parent?
I usually see both sides very clearly, and that means seeing the darker sides, too. I don’t have all the answers to this conundrum, none of us does. I know, though, that we need to keep the primary care office open so we all have medical homes. I know that pitting primary care against specialist care is unhealthy and will hurt patients, and in the end, will damage society, which is all of us. There is a better way. We must first see clearly what is occurring, speak up and work together for what is good and just, and keep our medical homes intact.
Jean Gunner has been director of operations at Buffalo Pediatric Associates since 1984.