August 2020, Volume XXXIV, Number 5
Addressing a systemic problem
Why we need a “Patient’s Choice” law
By Charles E. Crutchfield III, MD
n a recent article, “Institutional racism in medicine: It’s time for changes,” published in the July 2020 edition of Minnesota Physician (http://mppub.com/mp-c1-0720.html), members of the Minnesota Association of Black Physicians offered a first-hand look at the experiences and challenges faced by Black and other physicians of color. Institutional racism in medicine, and in every part of society, is much deeper and more complex than what can be illustrated by individual experience. In health care it also has significant impact on issues such as access, policy, and reimbursement. It is an insidious concept that hides so plainly in sight that those who promulgate its agenda often have no idea that this is exactly what they are doing.
It is a topic beyond the scope of a single article, especially considering that many in health care claim it could never happen in their profession. In this article we will shed more light on this important issue by addressing one of the most critical factors that affect patients of color: health plan exclusion of physicians in good standing without cause.
Here at home
For all its remarkable attributes, Minnesota has recently gained national attention in a way we would prefer to avoid. Our state has the ignominious distinctions of both having the widest disparity in academic performance between White students and students of color and the highest health care disparity between White residents and people of color. How can a state with the nation’s top-ranked health care system, the Mayo Clinic, one of the nation’s best academic health centers at the University of Minnesota, and well-developed regional health care systems fail to deliver favorable medical outcomes to its communities of color?
The reasons are varied. While experts can point to several demographic and economic factors, the most obvious is that Minnesota is in the minority of states that still permit health plans to deny health coverage for care by specific physicians. This includes even those willing to accept the health plan’s negotiated rates. The health insurers need not give a reason, and, in fact, they find it advantageous to provide no reason at all. Interestingly, if a health plan actually gave a reason for denying a patient their choice of doctor, the doctor may then have the right to appeal the reason provided. Quite simply, for the excluded physicians, “No reason given” means “no right to appeal.”
When cultural connections equal better outcomes
For centuries, American health care has failed—often deliberately—to prioritize the health care needs of Blacks and other non-White people. Much medical care is universal and can serve different ethnic and racial communities. However, we are gaining a better understanding of how patients attain measurably better health outcomes when they have access to a physician with a shared ethnic, racial, or cultural background.
Black patients who are treated by a Black physician achieve better outcomes.
Recent reports by National Public Radio (https://tinyurl.com/mp-npr), research by faculty at top institutions including the University of California at Berkeley and Stanford University (https://tinyurl.com/mp-uc-stanford), and a new report from the University of Minnesota, “Research Brief: Black newborns die less when cared for by Black doctors” (https://tinyurl.com/mp-umn-newborns), are building on the body of information supporting the benefits of this access.
These and many other similar reports conclude that Black patients who are treated by a Black physician achieve better outcomes. Specifically, Black patients were more likely to pursue more intrusive preventative medical care when recommended. Patients report better empathy from and comfort with doctors who share cultural, ethnic, and racial characteristics with the patient.
There are reasons for the better outcomes from a shared background between patient and doctor. These include the greater shared cultural identity of physicians of color to work with other people of color who are traditionally underserved and often live in economically depressed areas. They also have empathy for and familiarity with the specific health care needs of ethnic patients and a higher comfort level among minority patients, including the view that minority physicians take them seriously and respect them.
No margin for error
While Black Americans make up roughly 15% of the general population, Black doctors are only 4% of all physicians. With this significant shortfall in numbers of Black doctors to serve the Black patients, the exclusion of a Black physician from coverage by a health insurance plan has devastating effects on the health care structure and the care those patients receive.
If the goal is to improve health care outcomes for people of color effectively, then health plans must not exclude a doctor in good standing from being fully covered under the health plan. Based on the number of Black physicians and Black patients in Minnesota, a health plan’s refusal to cover care provided by a physician of color can have up to four times the negative impact on the Black community than would the exclusion of other physicians whose race and ethnicities are well represented in the medical community.
For health plans, it’s about money
Most patients are shocked, confused, and even scared when they first learn that their health plan won’t provide full coverage for care provided by a doctor of the patient’s choice. Why wouldn’t a health plan fully cover any licensed physician in good standing if the doctor is willing to accept the rates for service negotiated by the health plan? If Doctor A and Doctor B both accept the same payment for the same medical care, what’s the difference to the health plan?
The answer is control. Suppose the health plan doesn’t have the power to exclude a doctor from its panel of physicians for whom they provide full coverage. In that case, they have no leverage over doctors through the threat of dropping them from their panel, nor can they limit the convenient access to care for patients by permitting them to see a physician in their community.
After the Health Maintenance Organization Act of 1973 was passed nationally, Minnesota became the only state that did not allow for-profit HMOs. We were also one of the few states to allow health plans to exclude doctors from their member panels without cause. Only recently were laws changed to allow for-profit managed care, though they still may exclude doctors without cause.
Do nonprofits only have the interests of the patients in mind? With executives who make millions or even tens of millions a year running “nonprofit” health plans, making money remains a premium. On top of that, when Minnesota recently eliminated the requirement for health plans to be non-profits, the state indefensibly retained the right to exclude physicians for no reason.
Many people ask how the right to exclude physicians gives health plans leverage or allows them to make more money. Leverage comes from forcing physicians to use low-cost treatments for patients, even if the cheap alternative is not the best for the patient. By keeping a list of how each doctor stacks up in terms of cost, every doctor risks being dropped by a health plan if their costs are above the average, regardless of the population served by the physician. This unsavory deed is known in health insurance circles as “Economic Credentialing.” It is especially damaging to people of color, as many of their health care needs are higher cost based on health care disparities, including lack of earlier care and often poverty linked to poor health.
In short, health plans make more money by restricting access. Fewer covered physicians means longer waiting periods to get an appointment and longer distances to travel. These factors result in less care provided to the insured, which means less care for the health plans to pay for. Again, this is especially challenging for those burdened by health care disparities, many of whom are employed hourly. That makes it a challenge to get to appointments, a factor often compounded by transportation issues. These obstacles add to the difficulty in finding a physician with a similar cultural or ethnic background. The unwanted intrusion of the insurance carrier into the patient-physician relationship is questionably unethical and certainly abominable.
How do health plans respond to these criticisms? One Minnesota health plan was challenged after refusing to admit a Black physician to its covered physicians’ panel without providing a basis. In response to an inquiry, the health plan, PreferredOne, claimed that it already had enough physicians in that practice area and geographic area and didn’t need any more physicians in that specialty on its panel. (Although it was shown they did allow other physicians access to their panel in the same geographic area shortly after). When questioned about how excluding the additional physician saves money and—as claimed by the health plan—keeps premiums low by blocking one of Minnesota’s limited number of Black physicians from its panel, the plan’s spokespeople refused to respond.
Keeping the system of systemic racism systematized
Perhaps the baseless exclusion of a Black physician from a physician panel is merely a cost-saving measure that does not consider Minnesota’s health care disparity between its White and minority populations. This type of willful ignorance resulted in “red-lining” of Black and other minority neighborhoods that has kept generations of people of color in Minnesota’s lower economic strata. We now see that the same phenomenon has been playing out across Minnesota and the rest of the country for decades.
More pointedly, the White population—which is overly reflected among health care leadership in the United States—is not experiencing these same disparities. By contrast, the lack of access to minority physicians does not register on the health plans’ radar of concerns. This lack of awareness or turning a blind eye to the immoral difference in care based on race seen across Minnesota is mostly to blame for the poor health outcomes experienced by Minnesota’s minority community.
Health plans make more money by restricting access.
Times do change
Growing up in a medical household in Minnesota, I have seen an evolution in attitudes towards Black physicians in our state. My parents, both physicians, in the 1960s, were seen as Black people who were physicians. Over the past half-century, I have seen the attitude shift where I am seen as a physician, who happens to be Black. Subtle yet significant.
My practice is composed of 65% White patients and 35% patients of color. Physicians of color enjoy seeing all patients and serve all patients well. However, in a state with a significant disparity in outcomes by race, it’s important to recognize that patients from underserved communities may feel more comfortable being seen by a physician with cultural similarities.
For most patients, systemic circumstances minimize and typically eliminate any need for cultural connection with a physician. But for patients from communities that have not enjoyed those advantages, selecting a physician with a cultural connection or relationship will encourage access to better care and, according to the data, result in better patient outcomes and reduced health care disparities.
Now it’s time for a change
The Minnesota Legislature can end the right of health plans to exclude qualified physicians in good standing at any time. This appropriate change would bring Minnesota into the majority of states with a “Patient’s Choice” provision that permits patients to see the physician they prefer with full coverage by their health plan at the health plan’s negotiated rates. States that have enacted this provision—also referred to as “Any Willing Provider” or “Any Authorized Provider” acts—require physicians to meet the instate insurance network’s requirements, but limitations may apply, and self-insured plans subject to federal regulation are not included. The Centers for Medicare and Medicaid Services allows patients to go to any doctor, health care provider, hospital, or facility that is enrolled in Medicare.
Why shouldn’t patients be able to select a physician of their choice to care for themselves, their children, or their aging parents? This selection may be a physician familiar with the family or patient, or a physician with cultural similarities and understandings. Either way, this selection maximizes the chances for the best patient outcomes. It would also ensure that the limited number of physicians of color are available to Minnesota’s ethnically and culturally diverse communities. A “Patient’s Choice” law would bring improved health care outcomes for members of those communities.
Passing a Patient’s Choice provision improves the likelihood of a more productive relationship between doctor and patient rather than one hindered by the threat of a health plan dropping the physician, potentially impacting the physician’s treatment recommendations. It also increases the pool of physicians available to all insureds, reducing the wait to secure an appointment and expanding the geographic access to patients with mobility challenges.
With all of its exceptional qualities, Minnesota must not accept having the nation’s worst disparity in health care outcomes between its White and non-White populations. By eliminating health plans’ right to exclude physicians from the health plan panels for full coverage, Minnesota can begin to improve access to physicians of the same ethnic and cultural background as their patients, leading to better outcomes.
For patients of color, selecting a physician they connect with may be critical to improving their health care outcomes. This choice should not be taken from them, nor should it be withheld from anyone who wants to select a physician to care for themselves, their children, or their aging parents.
Adopting a “Patient’s Choice” provision will help all Minnesotans by ensuring access and availability to their preferred doctor and by restoring the doctor-patient relationship to focus on the needs of the patient without concern for the profitability of a health plan. Minnesota’s 20-year experiment with allowing exclusivity as an attempt at cost-saving has been unsuccessful and has contributed significantly to our state’s health care disparities.
We must make that change.
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