Doctors Fees Try Their Patients
By: Source: AARP Bulletin Today Date Posted: 2004-05-25 12:16:00-04:00
A growing number of doctors fed up with skyrocketing malpractice insurance premiums are calling on their patients to bear part of the burden.
Some physicians are requiring patients to sign waivers promising not to sue for "frivolous" reasons or, in some cases, for any reason at all. Others are billing for telephone consultations, paperwork and other services that once were free.
Perhaps the most controversial—and possibly illegal—approach is charging user, or administrative, fees. Patients increasingly are protesting paying more—on top of their copayments, deductibles and premiums—for medical services already covered by their health plans.
"Medical providers need to charge for care rendered," says Sharon Hall, a spokeswoman for Anthem Blue Cross and Blue Shield of Virginia, "not for administrative fees. Grocery stores don't charge you administrative fees for stocking the shelves. That's the cost of doing business."
But Lila Tinkoff of Oak Hill, Va., didn't mind when her doctor tacked a $7 fee on to her bill. "He said malpractice [insurance] rates are so high that this helps to offset that," says Tinkoff, 59. "I'm a nurse so I can sympathize with him."
Paul Kitchen, executive vice president of the Medical Society of Virginia, which represents about 8,700 physicians, says the fees are symptomatic of a "system in crisis."
"This is about recovery of lost income rather than a revenue-making scheme," he says. "Malpractice costs are going through the roof. These physicians are taking hits on their income. The economics in the medical world are so crazy that it's just become difficult to make a living."
POINTING FINGERS
Yet some consumer advocates and legal experts say the user fees are about more than raising money. They may be a way for doctors to "pull the patient into the debate," says David Studdert, associate professor of law at the Harvard School of Public Health, to alert them that escalating malpractice premiums are "a real problem and … [that] we're in a terrible situation here."
Though many doctors blame exorbitant rates on big jury awards to patients in malpractice lawsuits, at least one consumer group says doctors are pointing their fingers in the wrong direction.
A recent study of insurance rates in Georgia by the Washington advocacy group Public Citizen found that malpractice jury awards have remained nearly flat since 1997. In Atlanta, verdicts favoring patients decreased substantially.
"Medical leaders and lawmakers are blaming patient lawsuits for a so-called malpractice crisis," study author Frank Clemente said in a statement, "when all evidence shows that the legal system has nothing to do" with it.
One reason malpractice premiums have gone up, some analysts say, is because the insurance industry's revenue has gone down. Its "investment income declined," says Richard Hillman, director of financial markets for the General Accounting Office. "So to maintain a profitable stance, naturally premium income rates had to rise."
Sanford Melmed, M.D., an internist in Columbus, Ohio, says it's not only higher premiums that are squeezing doctors. It's also factors such as smaller reimbursement fees from insurance carriers and rising overhead costs that are driving him to charge patients for some services he used to offer for free. "We are just trying to survive," Melmed says. "In Ohio, practices are going bankrupt … because of the malpractice crisis."
ON SHAKY LEGAL GROUND
Nancy Udell, director of policy for Common Good, a New York-based bipartisan coalition that works on litigation reforms, worries that the tactics are "imposing a burden on the patient" and will hurt patient-doctor relationships.
But she blames a "dysfunctional" system for prodding doctors to fight back. "Literally anybody can sue for anything," she says, "and that's what doctors are reacting to."
Still, doctors who charge user fees for covered medical services could find themselves on shaky ground with insurance companies and federal regulators. By law, Medicare patients, for example, cannot be charged additional fees for covered services.
The Office of Inspector General at the U.S. Department of Health and Human Services issued an alert March 31 reminding doctors they could be fined or banned from Medicare and other federal programs should they violate those terms.
Officials at managed care plans are similarly concerned that their subscribers are being charged additional fees in violation of their contracts with doctors.
Sharon Hall of Anthem says the number of consumer calls about the fees has doubled over the last six months. Anthem has dismissed a few physician groups for such practices, she says, and warned others to "cease and desist."
Doug Gray, executive director of the Virginia Association of Health Plans, which represents managed care providers covering 3.9 million people, says charging user fees goes against the principle behind managed care—to negotiate rates on behalf of patients.
"Naturally we're concerned about it," Gray says. "I don't know whether it's legal or illegal. It shouldn't be happening."
In Florida, says Bob Lotane of the state Office of Insurance Regulation, physician user fees are illegal. Patients are urged to call the state's consumer hotline if they're asked to pay one.
DON'T SUE ME
Some doctors trying to discourage malpractice suits are asking patients to sign forms and waivers agreeing not to sue them.
David Vastola, a gastroenterologist in North Palm Beach, Fla., says he recently began using waivers after his malpractice premiums climbed in one year from $12,000 to $60,000—and coverage declined from $1 million to $250,000.
So far, he says, only one patient refused to sign the waiver. "I would not see patients if they didn't sign it," Vastola says. "Instead of charging my patients more, I use this as a tremendous disincentive" for them to file suit. He says dozens of physicians from around the nation have asked for copies of his waiver.
Two years ago, Jeff Segal, a neurosurgeon in Greensboro, N.C., launched Medical Justice, a paid-membership group that provides doctors with contracts for their patients to sign agreeing not to sue for frivolous reasons. If a patient does file what Medical Justice deems to be a frivolous suit, the organization will cover the physician's expenses to file a countersuit.
"We're no more intimidating than the Bible the expert puts his hand on when he says he'll tell the truth," Segal says. "Our goal is to keep the system honest."
Jackson Williams, legislative counsel for Public Citizen, says he doubts waivers would hold up in court if patients decided to sue for malpractice. "Doctors are lashing out at lawyers, and they're starting to lash out at patients," he says. "They're trying to drive home the point they're hurting, and they want others to feel their pain."
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