My patients got an HMO to take me back

But did the author win the battle, only to lose the war?

By M.P. Ravindra Nathan, MD
Cardiologist/Brooksville, FL

When I returned to my office from a two-week vacation in the summer of 1999, a nasty surprise awaited me. A large Medicare HMO, ProHealth (not its real name), had decided to terminate me and my partner, giving us the required two months' notice. A quick check on our office computer revealed that I was going to lose 440 patients, or about 15 percent of my practice.

I called ProHealth's provider relations supervisor immediately. He gave no explanation for the decision to drop me beyond an oblique reference to "business reasons." When pressed further, he offered that ProHealth was "consolidating" its position in our county and would be contracting with only one hospital and just a handful of specialists.

In talking to my peers, I discovered that a mass deselection had taken place. ProHealth had terminated three-quarters of its cardiologists as well as many vascular and cardiac surgeons, gastroenterologists, and pulmonary specialists. Local newspaper stories and my HMO contacts suggested that ProHealth was planning to pull out of the county, or at least scale back its involvement here. The word was that it was losing millions of dollars on its local Medicare business.

Why had I been dropped while other cardiologists had been retained? When I contacted the area manager of ProHealth, he told me that I didn't do enough volume in the hospital that was still participating with the plan. I knew that was untrue, since I was quite active in that hospital. I also knew I had treated my patients very well and that my care was comparatively cost-efficient. Perhaps ProHealth had simply picked a few cardiologists who were willing to give the plan a good financial deal, I told myself.

Nevertheless, I wasn't ready to give up. As the effective date of my termination approached, I mobilized support among colleagues and patients. First, I asked a few of my referring family physicians to write letters to ProHealth about the quality of my work. All of them did. I thought this would be effective because the plan wanted to keep its FPs happy.

Next, I composed a form letter for my patients to sign and mail to ProHealth. A number of patients had expressed sympathy for me, and some were really upset that they'd have to choose another cardiologist. So I had my staff call a dozen patients I felt especially close to, and they all obliged.

At the same time, my partner and I urged our ProHealth patients to switch back to traditional Medicare. Alternatively, they could have moved to another Medicare HMO that we belonged to. But there were rumors that plan, too, might be pulling up stakes, and I didn't want my patients herded around like cattle.

On the other hand, I knew it would be difficult for elderly patients on a fixed income to return to traditional Medicare, because it would mean losing their HMO-subsidized drug benefit and other things Medicare doesn't pay for. One patient with chronic heart failure told me, "I don't want to go to any of the cardiologists still listed on ProHealth's panel. But I can't afford these expensive medications, and I'm on six of them." So he stayed with the plan, although he wrote a strong letter on my behalf.

In the end, I lost all but about 30 of my ProHealth patients. Although that's a small number, I regard it as a victory, because some of my patients were willing to listen to me.

After my termination in September, I continued to treat ProHealth patients who asked for me when they were in the hospital or the ER. The plan had no problem with paying me for those services. It also paid me to do transesophageal echocardiograms, since I'm one of only three local cardiologists who do the procedure regularly.

But, despite my continued entreaties, ProHealth refused to reinstate me. Not even a recommendation from the CEO of the hospital swayed the plan. Then one day, I heard that a couple of other specialists had been reinstated, and, a bit later, I received a credentialing form from ProHealth. Soon I was participating in the plan again.

It turned out to be a short-lived triumph. Few of my former ProHealth patients returned to me; they had found other physicians and didn't want to leave them. And not long afterward, ProHealth finally left the county. The HMO to which ProHealth had sold its patient "lives" also announced its intention to depart. That would leave the county virtually free of Medicare managed care. But local residents and their legislative representatives protested. Now, other plans have come in, and I'm getting on their panels. How could I not?

The plain fact is that HMOs are here to stay. No cardiologist in my area can stay in practice with nothing but fee-for-service revenue from traditional Medicare and Blue Cross Blue Shield. So we have to participate in the HMOs and stay in their good graces. Yet I feel I struck a small blow against managed care companies that toss us to the winds whenever it suits them.

The plans don't treat patients very well, either, when they walk away from some areas because it suits their purposes. But one thing I learned from this experience is that insurers will listen to patients when they stick up for their doctors—especially Medicare patients, who are free to switch plans. They know that if they make a patient unhappy and he starts spreading rumors, he'll leave the HMO, and others may leave, too. So if a plan drops you and you want to be reinstated, your most powerful weapon is your patients.

 

M.P. Ravindra Nathan. My patients got an HMO to take me back. Medical Economics 2001;5:118.