Aug. 25, 2001, 8:49PM
Business-vs.-medicine conflict dictates care
Dermatologist drops Blue Cross, affecting 1,000
By SUSAN KREIMER
Copyright 2001 Houston Chronicle
In a letter in May, Dr. Elizabeth Basler and her associate at Medical Center Dermatology informed about 1,000 patients that they would no longer accept Blue Cross and Blue Shield of Texas.
"Although this has been a difficult decision, we have chosen to make this change because of the administrative requirements of these plans," the doctors wrote. This means that patients covered by the plans would have to pay out of pocket and seek reimbursements from the insurance company themselves.
Basler had cared for patients with Blue Cross plans for 11 years, and they represented about 20 percent of the practice. But, she said, it was by far the hardest plan to deal with, and her complaints fell on deaf ears.
"I hate for the insurance to come between me and the patient," Basler said. "Because I run a small business, I have to think of my office operations, and I can't let one plan bog us down."
The conflict between medicine and business occurs repeatedly at doctors' offices in Houston and across the country. Battles brew over reimbursements, tardy payments and the claim review process.
In the case of Medical Center Dermatology, technology alleviated some of the doctors' headaches with other plans. When Basler voiced her concerns about excessive paperwork to Aetna, Dr. Susan Mueller, one of nine medical directors employed by Aetna in Houston, suggested that they try a program to handle claims and referrals electronically. The system has helped speed things, Basler said.
"We never really like to have any physicians terminating for something we can fix," said Mueller, an internist.
A number of health insurers also have introduced such electronic methods to streamline the reimbursement process. And they have brought aboard more medical directors who can relate to the concerns of practicing physicians.
In addition, they've moved away from a fixed payment system that heightened doctors' financial risk, if the costs of care exceeded their intake of funds. Capitation -- a set monthly payment per patient -- often has been replaced by a discounted fee-for-service arrangement, which reimburses a set amount for each procedure.
But none of these things matters unless the two sides agree on the reimbursements.
Blue Cross is one of the health plans with an electronic payment system, but it didn't solve Basler's problems. Two years ago, Blue Cross launched Blue Link, an Internet-based or automated telephone system that allows primary-care physicians and hospitals to approve referrals and hospitalization 24 hours a day. About 70 percent of such authorizations are now done that way.
Since 1994, Blue Cross also has administered the Texas Health Information Network, enabling doctors and hospitals to file claims electronically.
Basler said she wasn't informed about the Blue Link system for referrals, but even if she had known, the expense of a more sophisticated computer and a second phone line -- in addition to training her staff to implement the program -- wouldn't have been worthwhile.
She used Blue Cross' electronic billing system, Basler said, but it was time-consuming. Blue Cross required the dermatology office to fax a patient's medical records for the services rendered more often than other insurers, she said.
Physicians often feel there's less friction with managed care if they can call a medical director at an insurance company to express their patients' needs.
"Sometimes there are unusual situations where they need to go to somebody out of network. That requires a very narrow type of specialization," said Dr. Richard Nelson, a medical director who oversees credentials of physicians and resolves complaints at Blue Cross.
"We have to consider those issues in the same way as if they were our own patients, to make sure these people receive the care they're entitled to," he said.
Aside from squabbles over billing, some doctors leave networks for personal reasons -- they retire, switch careers or move their offices -- and patients seldom quibble about that. It's when providers become fed up with the bureaucracy of health plans that patients feel an insurer has stepped in to dictate medical care.
Emily Buckles felt this way because two doctors she had been seeing -- dermatologist Basler and a gynecologist -- wouldn't take Blue Cross.
"There are bad doctors out there, and you don't want to just open your Blue Choice booklet and pick a name," said Buckles, 37, a paralegal at a small downtown Houston law firm who had a cancerous growth removed from the tip of her nose five years ago.
"When I found Dr. Basler, that was the result of six months of asking people for recommendations -- co-workers, friends, relatives. Two months later, I got a letter in the mail saying that she wasn't going to accept Blue Cross and Blue Shield anymore, so now I'm back to square one."
Buckles will switch to another dermatologist in the network who will monitor her for symptoms of a recurrence of skin cancer.
But when her gynecologist gave up on Blue Cross, that was another matter. Buckles had established a rapport with this doctor and wanted her -- and no one else -- to perform a hysterectomy. To ensure that she would be covered, Buckles' husband, Greg, added her to his insurance plan as a dependent, paying about $50 more monthly. Then she paid $175 out of her pocket for a visit and another fee for a lab test.
"If there were no insurance, we'd be in a world of hurt because medical care is so expensive," Buckles said. "But at the same time, it seems like they make it very hard to use your insurance."