On the Brink

"We worship an on-time God." - Bill B, worship leader at my Baltimore church

As I drove to work this morning, I started thinking about how on earth I was going to break it to about 800 of my patients that I will no longer be in network with CareFirst (BlueCross/BlueShield).  The decision to resign my contract came after much distress, more like "cognitive dissonance".  Back in January, after receiving a rejection letter from the Maryland Health Care Commission, I started feeling like the writing was on the wall.  I had reviewed numbers from 2010, and it turned out that CareFirst had only paid 1/3 of what was charged.  We took a close look at denials and realized that many denials were due to policy changes our patients were not aware of.  The biggest of these was lack of coverage for annual preventive visits (as if preventive medicine doesn't save CareFirst oodles of money, they just seemed to want their cake and to eat it, too!).  

One claim from last spring was denied because I neglected to document the last menstrual period for a 60 year old woman!?!  At times like this, one is tempted to growl "WTF!"; however, my mother did school us never to swear, as swearing is uncivilized.  I started coming to the conclusion that there was a strategy involved, based on the "learned hopelessness" experiments involving rats in mazes.  It is unfun to be the rat in that situation, especially when relying upon the insurance companies for bread.  It was kind of extreme to have taken a pay cut last year despite working 20% more hours.  


Getting paid sub-professional wages is one thing; but it is truly the illogic of it all that kills me.  Why on earth would doing good not be rewarded?  Maybe because evil exists, or is it perchance simply laziness or myopia on the part of the insurance companies not to see that good doctors, even the most devoted, are on the verge of burnout?  I knew I was in trouble when, last Christmas while sitting at a fireside with my brother-in-law,  I started talking to him about the possibility of leaving medicine altogether.  I think the pressures of being a doctor, a small business owner of a recent start-up, and a patient all caught up with me.  

I have been financially stressed for the past 5 years despite a really thrifty lifestyle.  It is true that most of my clothes are from second-hand stores.  When I needed a new car last year because I couldn't drive my stick-shift while recovering from knee surgery, I bought a 2003 used car rather than a 2010 model.  I drive a Honda Civic, true that it's a hybrid, but I even save on gas.  I haven't left the country on vacation since 2008, and I don't have a golf habit.  I pay my credit cards off in full every month, and I don't like shopping.  So why should I have less than a month of expenses sitting in my bank account?  


On the productivity side, I can't imagine seeing more than 80 patients per week.  I am not interested in doing botox as a side business and have been too tied up lately to think of other cash revenues.  But why should I have to?  I should simply be paid as a professional.  I don't need a lot, really.

As I drove to work this morning, I kept thinking of the image of the woman who fell into quicksand, struggling to grasp at a slippery edge, slipping into the mire.  That is what it has felt like to deal with CareFirst and the other insurance companies from whom I have resigned contracts over the years.  Various statements insurance companies have told us over the years:

"Internists in your area are a dime a dozen."

"We don't negotiate with small practices."

"There are plenty of internal medicine doctors in your area to replace you." (last year)

"Why should we make an exception for you?"

"If you were a larger practice, we would negotiate with you."

What should follow all of this?  "If you were a man, we would negotiate with you"?  After all, recent studies have shown that women doctors are paid less than their male counterparts, even correcting for work hours and within the same specialty.  It is time, again, to demand "equal pay for equal work."  I have joined the ACP Health Policy Committee and recently wrote a bunch of resolutions about equality; however, traditionally the general practitioners have lacked political clout, as our organizations are not as generously funded as the AMA.  After all, generalists are underpaid and thus have less money to contribute and are overworked and thus have less time to contribute.

Pretty much, all of this was in my head for the first few hours of the day today and for most of the past few months as well, especially after the bad news in January.  We found out then that we weren't chosen by the Maryland Health Care Commission as a Patient-Centered Medical Home Pilot Program site this January.  The arrival of the rejection letter coincided with the departure of my last hope for a favorable option.  I was crestfallen.  I sent my resignation to CareFirst the next day.  I later wrote the MHCC asking for advice on how, now, to negotiate with insurance companies.  How, without the State's backing, would I possibly be fairly compensated for pushing forward with the model of excellence I have so wanted to pursue?  Turns out, my first letter went unanswered.  I rewrote the letter and sent it up-the-chain to the head of the selection committee.

To my surprise, he replied and asked whether or not I was still interested in the Pilot Program, as some of the selected practices had opted out.  Of course, my answer was a resounding "yes!"  He told me that the committee was planning to invite a few more practices after more decision-making.  Having faced huge disappointment with the first go-round, I dared not hope very much.  He promised to look into things.  I followed up.  I even wrote a letter to the Selection Committee highlighting my commitment to the Medical Home Model.  I'm even going to the PCMH Summit Conference, on my own dollar, in Philadelphia from March 13th-16th.  What's not to love about me?  I sent my letter a couple of weeks ago and had really stopped thinking about it.

Then today, around noon, I thought of contacting him.  Or would a letter come in the mail? Maybe best to wait.  I moved on to other projects.  Then around 3 in the afternoon came a phone call from the MHCC.  Had I received their e-mail?  No.  Perhaps it bounced?  Well, turns out that they were calling to let me know that our practice was selected!

This is totally crazy.

God's timing is totally crazy, and even though it does say in the Old Testament, "My ways are not your ways, saith the LORD," I am still having a hard time believing the timing.  Turns out that my CareFirst Maryland contract is set to expire on March 11th, and the rest of the CareFirst/Blue Cross contract is set to phase out on April 11th.

What to do?  I guess I have a pretty big decision to make.  The MHCC Pilot Program incorporates a favorably negotiated contract; though, CareFirst was still my lowest payor.  In my heart, though, I really want my patients to have me as their doctor.  My patients and I, many of us, have been a team for years.  I have put a lot of effort into patient care and a lot of heart into those relationships.  I still feel devalued by CareFirst, though, and it runs deeper than just me. I feel that CareFirst is not on board with recognizing internal medicine as a profession.  I have felt disrespected.  I could just work with the other MHCC-sponsored insurance companies who seem more reasonable.  Is the MHCC deal sweet enough to re-engage in negotiations with CareFirst? Will it be in time?  Should I rescind my resignation? Tune in for more, or if you can't sit still, then write them a letter.