How claim denials broke one camel's back
When Melvin Kirschner, MD, a family practitioner in Van Nuys, CA, started working with HMOs 10 years ago, he thought it was a good idea. "My patients were pulled into them from their employment, and I believe in managed care. I'm the first to admit that sometimes I need guidance - maybe I do a few too many tests. So I didn't object to the idea," he says.
But what started out looking like a positive move quickly changed, and over the course of 10 years, Kirschner saw his capitation rates cut in half, his paperwork commitments rise, and the incidents of nonphysicians wantonly denying claims and directing care skyrocket. By 1997, he'd had enough and he quit.
"I joined these organizations and saw my private practice sucked away through this marketing ploy. I have a good name and 35 years in the community, and they used that."
The capitation, initially $10, was cut first to $8.50, and the HMOs began asking for an increasing number of reports. "I was spending more and more time on paperwork, and then they cut [the rate] again, to $8. Then they started sending more rejections. There were delays, and they cut the cap to $7.50."
One of the most serious delays was a patient who had an acoustical neuroma, a very specific kind of brain tumor. "There is only one group in our area that had experience with this, but it wasn't on the patient's list," he recalls. The HMO sent the patient to their own neurologist, who agreed that the patient should go to this out-of-plan group. Again, the HMO balked, finding a neurosurgeon who had never done this type of surgery but was willing to try it. "I said I wouldn't let my patient go to someone who hadn't done it before," says Kirschner. "I insisted on this."
Meanwhile, so much time had passed that when the patient was finally admitted to the hospital where the out-of-plan group practiced, he needed another MRI. The HMO, which had no agreement with that hospital for MRIs, insisted the patient be released from the hospital, taken by car to a hospital 20 miles away to have the MRI done, taken back to the first hospital, and readmitted for the surgery. "What a big hassle!" Kirschner says.
There were other incidents which sounded a warning to Kirschner - like the patient with a rash he hadn't seen in 35 years of practice. "I wanted a dermatology consultation, but [the HMO] denied the request and sent me - without seeing the patient - a proposed treatment for the rash." Kirschner won that argument, too.
Meanwhile, his per member per month rate was cut to $5. "I was working for nothing. But they said it was only temporary." But when the next contract came, there were clauses in it that bothered him - they could fire him with only one month's notice, while he had to give three months. He was required to do house calls and six days of hospital care for no additional fee.
But Kirschner's breaking point was a patient with a back problem whose care was initially approved and then retroactively canceled. "I finally quit. I told them if they ever were sued by him, I'd be an expert witness without pay. They pointed to my contract, but I told them they never sent back a conformed copy of the contract I changed."
That was 18 months ago. Since then, his income has halved. His daily patient load dropped from 20 to 10. For a few weeks, there were just two or three patients a day. But his patients are loyal, and many are finding different payers or opting to pay out of their own pocket for Kirschner's services.
He has become a one-man band against the excesses of HMOs. His letters have been printed in Time magazine and USA Today. He has written columns in his local paper, too. "I consider it a privilege to be a doctor. I'm not in it for the money, but for the love of taking care of people. It's not about money; but principle," he says.
Kirschner is embarrassed by the attention he gets from people when one of his letters appears - they inevitably generate calls from would-be patients. "I'm not doing this to market my practice," he says. He'd rather his message got out to physicians, not patients. And that message is simple: "I want every physician in the United States to drop HMOs. They talk a good line, but they take away patient care money and use it for their own devices. We [physicians] created Blue Shield of California and Kaiser. We made these to care for patients. But when you put a business intermediary into it where profit is the only motive, then there is a clear need to change."
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