Doctor sees insurance remedy in health reform

Dr. Scott Nelson has found a growing problem among his patients in rural Mississippi, and it's not related to a disease.

More and more patients, he says, have extremely high deductibles in their health insurance plans. As high as $5,000. So they must pay that amount out-of-pocket in a year before insurance kicks in.

Nelson, a family physician in Cleveland, Miss., treats many people with chronic medical conditions such as diabetes and hypertension. They require ongoing care for those conditions, but it's out-of-pocket costs – amid a recession -- that lead an average of two patients a day to walk out of his clinic without getting needed tests, he says. "A lot of sick people need a lot of monitoring,'' he says.

Such insurance problems have helped convince Nelson to support the movement to overhaul the nation's health care system. Not only would reform help patients receive proper care, he says, but it also could boost his practice financially.

Doctors are far from united on health reform. Some major organizations, though, have moved to support the proposals coalescing in Congress, a shot of adrenaline for President Obama and advocates of an overhaul.
The American Medical Association earlier this month endorsed legislation moving through the House. The American College of Physicians and the American Academy of Family Physicians have also backed reform efforts.

Nelson, 45, looks upon reform from his rural Mississippi perspective. He has been a doctor in solo practice for the past four years in Cleveland, his hometown. Office overhead, though, is higher than he anticipated -- rent, salaries, malpractice coverage, equipment, insurance hassles. His business is marginally profitable.
"Cash flow is pretty sporadic,'' he says.

Health reform as it now stands is a confusing, elusive target. Nelson welcomes the talk of bonus pay for primary-care physicians like himself, but he's not sure what final legislation will actually produce. "I don't think I've met a physician who really has a good grasp of it,'' he says.

He wants any legislation to preserve patients' ability to choose their doctor, and physicians' autonomy to order medications and tests.

Extending coverage to people without insurance -- about 5% of Nelson's practice -- ''would help tremendously,'' he says. People with chronic disease need care early before medical conditions worsen -- when treatment becomes more expensive.

And he would embrace a prohibition on health insurance companies from rejecting people with pre-existing medical conditions. ''An ongoing nightmare for patients,'' he says.

But the under-insured situation needs fixing, too, Nelson says. These people have coverage, but their deductibles and out-of-pocket costs make affording medical care difficult, if not impossible.

"Deductibles have skyrocketed,'' he says. Employers and individuals have not been able to maintain the same coverage, he says.

With a $5,000 deductible, few patients are going to reach that point where their medical spending triggers their insurance coverage, Nelson says. About half of his patients with private insurance have high deductibles.
His patient volume is decreasing by 10%, which he largely attributes to insurance problems. Better coverage for more people could help his practice revenue, he says.

Currently, Nelson says, "I have no choice but to ask to be paid at the time of service. My profit margin is slim. That puts a patient in a difficult position.''

Such concerns about patients' access to care have driven many physicians to consider the positives of health reform, Nelson says. He adds: "Virtually everyone realizes that something's got to be done. ''

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