Physician licensure targeted

Why doctors object to a pending health plan bill

Doctors and health care attorneys are up in arms over a bill pending in the state legislature that would tie physician licensure to participation in a proposed affordable medical plan for small businesses.

They contend that such a change could drive doctors into bankruptcy while exacerbating the already dramatic shortages of Massachusetts physicians in critical specialties.

Meanwhile, advocates for the insurance industry say the bill - which would also tie reimbursement under the plan to Medicare rates - is a necessary measure to address the crushing burden that health care costs are placing on small businesses.

“This proposal is designed to give almost immediate relief to small business,” said Dr. Marylou Buyse, outgoing president of the Massachusetts Association of Health Plans (MAHP). “It’s designed so that it’ll decrease premiums up to 22 percent. That’s a huge cost savings at a time where the economy is challenging and healthcare costs are on the rise.”

But Massachusetts Medical Society President Mario Motta, a Salem cardiologist, blasted the plan as a “ruse by insurance companies” to get the government off their backs.

“We all know small businesses are hurting and need some relief,” said Motta. “But [the insurance industry] created this problem and now they want to shift blame to somebody else. I find this a bit offensive, to be frank.”

The bill, S. 2170, was introduced in July with the support of MAHP.

It would create a new “Affordable Health Plan” for businesses with fewer than 50 employees. The product would provide benefits equivalent to the Commonwealth Choice “Bronze” plan, the most basic level of coverage available above the young adult plan.

The bill would also require any provider that already participates in an existing health plan to participate in this new plan. Additionally, it would cap reimbursement under the plan at 110 percent of Medicare rates while barring providers from balance-billing to recoup costs. Providers failing to comply would be subject to loss of their medical license.

If the proposal passes, it would sunset upon implementation of sufficient recommendations from Gov. Deval Patrick’s commission that is currently examining health care costs.

The wrong approach

Either way, the bill’s critics contend that it’s the wrong approach to a legitimately serious problem.

For one thing, said Charles Alagero, general counsel of MMS, it’s completely inappropriate to tie licensure to participation in an insurance plan.

“What does an insurance contractual matter have to do with one’s license?” Alagero said. “Tying a license to a contractual matter seems fundamentally counter to what licensing is all about, which is protecting the public and ensuring competency.”

At the same time, said Motta, the bill puts doctors in a financially untenable position.

“What they’re saying is, if you take any insurance product, we’re forcing you by law to take another product you didn’t negotiate for at a rate below the cost of doing business or else you can’t have a license in this state,” he said. “There has to be some reality testing here. To mandate anything tied to Medicare rates - where you make no profit at all or even lose in many cases - means there is no profit. You have to make a profit somewhere if you’re going to stay in business.”

Attorney William S. Mandell of Pierce & Mandell in Boston agreed. He also said that it’s particularly risky to add another condition to licensure in a state that already places disproportionate conditions on doctors’ licenses.

“What good is access to health insurance if you cannot find a primary care physician or get an appointment with a specialist for three months for a serious condition?” said Mandell, who advises medical practices. “We are near meltdown conditions with our physician supply in Massachusetts and this bill could be a shock that the system will not be able to endure.”

Mandell also questioned the wisdom of tying reimbursement to Medicare rates before examining the impact of radical changes to Medicare’s specialist reimbursement schedules that take effect in January.

One of many products

Buyse downplayed these concerns, noting that this product would be one of many in the marketplace.

“We don’t expect that there are a large number of people who would even take this product,” said Buyse. “Even though [the "Bronze" level plan] is the most popular in the Healthcare Connector, it still has a total now of only 35,000 people.”

Further, Buyse said, the rate paid under the pending bill would cover physicians’ costs and “give them a small margin.”

“Most physicians, if not all, accept Medicare,” she said. “I admit [this plan would reimburse] less than commercial plans, but [if such rates were so unprofitable] we’d see physicians not accepting Medicare.”

Buyse also rejected suggestions that the bill was an effort to shift the burden of cost-cutting to doctors without requiring insurers to cut their own allegedly bloated administration and marketing costs.

“This is the one proposal that goes directly to the heart of why health care costs are going up, and that’s increased provider rates,” she said. “Meanwhile, since health care reform [passed in Massachusetts], health-plan administrative costs have come down and profitability has gone down by more than a third. So I think insurers have already done whatever they can to make their administration as efficient as possible. I’m not sure that’s true for the provider side.”

Questions or comments should be directed to the editor at: reni.gertner@mamedicallaw.com