New Mexico in Focus; 303; HMO Patient Bill of Rights

Why are New Mexico doctors leaving the state? Is it dissatisfaction with New Mexico or with the state's managed care organizations? Coming up, a physician shortage creates a health care crisis in New Mexico, next on in focus. Hello and welcome to Infocus, Somarsi Chapa.

A rebellious house last week decided resoundingly to grant Americans a new set of rights to increase their clout against managed care plans, including broad freedom to sue health plans that deny patients the medical care they want. The legislation approved on a vote of 275 to 151 makes it easier for patients to visit the doctors they prefer. Get emergency room bills paid as well as giving them new powers to protest HMO's medical decisions in and out of the court. Once celebrated as forward-thinking, super-efficient organizations that would put a needed squeeze on doctor and hospital bills, HMOs and other managed care plans are enduring a wicked backlash, frequently accused of irresponsible and potentially dangerous penny-pinching at the expense of patients stripped of medical options they once took for granted. In New Mexico, the change from fee for service to managed care has had a significant impact

on the retention and recruitment of physicians. Here to talk more about that and other concerns of the medical community is Dr. Peter Baudet. And here to give us the legislative perspective and what kind of health care system the state will be considering this winter is Senator D. Feldman, thank you both for joining us today. Dr. Baudet, I want to start with you. You were the past president of the New Mexico Medical Society, which has about 3,000 members, right? Correct. Correct. So I imagine that you have a pretty good idea of what some of the complaints were of doctors. Yes. In the state of New Mexico, the society is concerned number one because of the number of physicians who we feel are leaving the state and we're trying to get a handle on exactly why that's happening now. As a matter of fact, with the cooperation of the state health department and Secretary Alex Valdez, we recently sent out a questionnaire to about a thousand physicians surveying those people, particularly those physicians who are planning to leave the state or who have left the state.

We're also more concerned about attracting good people to the state, it's not only keeping people here, it's we want to get the best people we can to come into the state. One of our concerns also is the rule, obviously New Mexico is a very rural state, we're very concerned about keeping good physicians in rural communities. We don't want them on Albuquerque or Las Cruces or Santa Fe. And part of the problem there is that the Medicaid reimbursement in this state is so low that we're losing physicians. The Medicaid reimbursement rate is based on 1977 figures. And so one of our goals in this state is hopefully to bring those reimbursement rates up to Medicare rates, and Senator Feldman can probably speak to that better than I. But that's another issue we'd like to do, we'd like to work on. We're also concerned somewhat about our relations with the HMOs. I don't think the relations are quite as bad as they're always made out to be, but health care isn't a transition, and the HMOs are part of that transition. Physicians are losing some of their responsibility and their care of patients, they're losing control over this, and physicians are concerned about that.

And again, this is this part of the transition of health care in New Mexico. Now you gave me some data of some of the physicians that have been leaving New Mexico, and for example, hospitals reporting. I want to show you a graphic of some of the doctors that have been leaving, like from Hila. If I could see that graphic please, there we go. Physicians reporting, Hila Regional II, LIA Regional IV, Belan II, and you can see Presbyterian 75, which includes 48 specialists and 27 primary care, CERA Vista I, St. Joseph 66. Why are they leaving? You know, a health care access is something that the legislature is really concerned with, because we feel that even citizens in rural areas should have equal access to medical care that do the residents in the cities. And you know, ironically, UNM, hospital, and the medical school has such a great program, primary care program, such an effort is made to attract people to practice in rural areas.

They have a special program for that, but all of that is really been threatened by the managed care environment, and particularly, I think, for UNM Hospital and for the Children's Psychiatric Hospital, which is, I think, suffering great losses because they're professors and their doctors are spending a lot of time on administrative work and less time on teaching and seeing patients. In fact, I had a conversation with the people from the Children's Psychiatric Hospital. They presented to the Health and Human Services Committee recently. They said they were looking at a $3 million loss as a result of Medicaid managed care. And as you know, the state has put the whole Medicaid system into a managed care system in order to save money and stem the rising costs. Dr. Baudet, you mentioned that some of the most pressing issues that doctors were concerned

about was low Medicaid reimbursement, hassle factors of HMOs, and then the gross receipts tax. Gross receipts tax. Have you been able to address any of these, or are you working on that? Well, I think these are all ongoing issues, and these are issues that Senator Phelma is going to be involved with, I'm sure, in the legislature within the next year or so. I think the most pressing need, again, as I mentioned, is probably to try to bring at least Medicaid reimbursement up to levels of Medicare in this state. It's interesting, and it's not a well-known fact, that Medicare rates are not the same in every state. Several years ago, Hickva, who administers Medicare, basically set reimbursement rates for each state, basically based on their cost of living. So if you get a gallbladder operation in New York City, for example, it's much more expensive than it is in Albuquerque. These rates have not changed for the last 10 to 12 years, whereas obviously the cost of living has gone up in these areas.

And so basically even the Medicare rates in New Mexico are, I think, the second or third lowest in the whole country because when the forming was first devised, that's how it was appropriated. And so even bringing up to Medicare level is not very high. The Medicaid rate, as I said currently, is based on 1977 levels. So some of these physicians in rural areas really can't make a living based on Medicaid reimbursements. Senator Phelma, what are the chances of increasing the reimbursement? This has been a under discussion in the Health and Human Services Committee and as well as a legislative finance committee. And I think there's a growing consensus that we need to phase in and increase in the reimbursement rates in order to maintain and attract physicians. This past year we increased the Medicaid reimbursement rate for dentists because we're having trouble in the rural areas with dentists especially and attracting dentists to rural areas is even harder than attracting doctors.

So we did that last year. It's at a cost of the state of about 15 million. And I think it's time that we also do the same for doctors. New Mexico is one of the few states that has a gross receipts tax on medical services too. And I know that there's been a lot of discussion amongst doctors and health care providers on removing that tax as well. That's a big one. That would cost the state about $57 million every year. And that's a pretty big lump. So we'll have to think about that. Dr. Bowden, is that why a lot of doctors are leaving or not coming to New Mexico? Well, I wouldn't say that's the primary reason. I think that most of us who are in New Mexico and join New Mexico. And I think we're not really whining about this or that. Well, I think there are some things that we can work on and this is one of the factors. For example, if someone moves from Clovis to Lubbock, they immediately double their

salary because number one, they're not paying gross receipts tax and then they don't have a state income tax. And I think most of us, as I say, enjoy living in New Mexico and we're not going to leave. As I mentioned previously, we're very concerned about attracting good people to the state. We want to get good people to come to the state. Frankly, I personally am not as concerned about keeping good people here, but I'm really more concerned about attracting better people to come and take care of the population here. Well, these numbers are pretty serious. If we could also show another graphic, this is the reporting from the county medical societies, Las Cruces, and these are doctors that have been lost from period of 1998 through June 1999. 55 doctors? Correct. Is that correct? That's correct. That's pretty incredible. Right. And even just most recently, St. Joseph Hospital has lost most of their pulmonary specialists because they just couldn't keep them. They're even having people come from out of state on the weekend to cover some of their pulmonary services. We recently lost our largest neurology group in Albuquerque because they couldn't make

it economically, and they basically group just dispersed. And so these are real things that are happening, and unfortunately, I think the state is going to suffer because we're all leaving some good people. Senator Feldman has the state grasped the severity of the situation? Well, I don't know whether the state has grasped the severity of the situation, but I know that I have. And these sound like statistics until it happens to you and my own doctor quit the practice of medicine about December of last year, leaving several thousand of her patients scrambling to find new doctors. So there's a whole lot of dislocation that occurs, and we as legislators hear about it from our constituents, and of course, we have our own personal experience. One of the things that I certainly would want to ensure in a managed care environment is that any savings, medical savings, is not done on the backs of doctors and on the backs of patients.

I think that has been our primary concern in the legislature. And that has spawned a whole bunch of legislation ranging from the Patient Protection Act to some protection for doctors in terms of the hassle factor. We did pass a legislation that said that managed care companies must pay within 45 days on a clean claim. And we have heard a lot recently about some of these hassles, and whether that law is actually being honored more in the breach than in the practice. And so we've got to, because the important thing is not just the statistics, but it's also the morale of the doctors that are still here. Because those are the people that are going to be treating us, and we want their morale to be very high. Dr. Bo-Dette, you're in the liaison committee for managed care, and so I know that you

have an opportunity to talk with HMO representatives and medical directors. What is there feeling about all this criticism and backlash that we're talking about? In the committee that I'm on, and it involves all the HMOs in the state. And I can sincerely say that I think they are very interested in having the most efficient best caring system that they can have. And they want doctors to be happy too, because their system is going to work better if the doctors are happy. And I can say on the committee that we're working with, in the liaison committee, with the HMOs, I think they've all been very cooperative and very helpful. I think they obviously, though, are constrained by either corporate or illegal technicalities that may not allow them to do some of the things they would like to do. And basically, an HMO is an organization that organizes a certain amount of patients, and organizes a certain amount of doctors, and puts them together. And the question is, in the overall scheme of things, how much value does that have in our medical system?

Because you're putting another entity between the patient and the doctor. If that has value, then I think it will continue in our system. If it doesn't have value, then I think the HMO is, we're just in a transitory phase to another system of medical care. And how efficient the HMO provides that care, and how happy they keep the patients and the physicians, I think will really determine whether or not they're continuing force in our society. And of course, I think that's of great concern when it's public funds, as in the case of Medicaid, that is going into the HMOs to care, and then to the doctors and the health care providers. It is another level. And in the case of behavioral health, with the Medicaid managed care, there is an even secondary level, because each of the HMO's contract with a behavioral health provider. And we have been hearing plenty in the past months about the difficulties, particularly, for mentally ill children in accessing those services.

Well, even though we've gone to managed care, we still remain one of the highest and insured, have one of the highest and insured rates in the country. And I think the one rate I read that is 33 of the states, county still remain medically underserved. I mean, that's two different statistics. But I thought that HMOs and managed care was supposed to change all that. Right. And it is ours. And I really, I think, agree with the attempt by the state to bring the underserved population into this managed care system. But it really becomes one of an educational process, too, because most of these people have not had the luxury of having a family physician. And they're only resource to medical care has been the emergency room. And it's very difficult to break that training, if you will. As I mentioned before, at Presbyterian Hospital in the emergency room, the highest scene complaint is middle ear infections.

And those are children who are coming the middle of the night on the weekend who should be going to their primary care specialist. But again, the system is not working yet because those people in the system, again, have not been educated to the point that they really don't know or don't trust or, you know, haven't learned to use the family, their family physician. And so the system is still expensive because it's not being used properly, I think. And there are some solutions to that that are not necessarily medical solutions. There's been a great deal of talk about instituting a home visiting program for young families and at-risk families to teach them parenting skills, to teach how to access the facilities that are available to them, and how to raise their children in a healthy way. At the beginning of the program, I talked about the patient bill of rights that was passed in Washington. And that still has to go through the Senate, so it may not be the law of the land. But what kind of protection, patient protection rules, is New Mexico going to be looking

at? Well, RC, we already have a Patient Protection Act. And as Dr. Vodet mentioned, the HMOs did cooperate in forming that act as it was passed. And that bill provides for basic consumer protections in the face of these large organizations in whose interest it is financially to limit care. Patients and consumers must have protection in that environment. And so this Patient Protection Act was one way to do that, and it provided for fair and prompt grievance procedures that enrollees know about all the forms of their coverage. It prevented gag rules, it prevented incentives to doctors to deny care to patients. It said that emergency room care, if someone felt what it was necessary, should not require a prior authorization.

It set up a system of enforcement through the Insurance Division of the New Public Regulatory Commission. It was all a real triumph, I think, for the state, for us to have this Patient Protection Act in advance of the federal government. There are still a great number of people that are not covered by the Patient Protection Act. All the ones that are covered by the federal programs, the Sandia employees, and so on. And that's why a federal bill is very important. Another aspect that the state bill does not provide is this very controversial provision for regarding liability. And this has been something that was passed in Texas, and you may know about that, Dr. Baudette. But the idea is, who should be liable in cases where the denial of treatment or restriction of treatment, which was mandated by an insurance company, caused death or illness?

Should it be the doctor that treated that patient or should it be the insurance company? And I believe that the bill that just passed the House does have a provision that the HMOs would be liable. What are the chances of it passing through the Senate as well? Do you know? I think probably, in its present form, probably not very good. I think just because of the, I think the Senate, a comparable Senate, does not have those same provisions. And so if they pass something, that's probably one of the things that will be left out of the bill, but I'm only speculating. But it was a pretty significant vote. I think what did I say? It was 275 to 151. What does it say about the HMO lobby? Are they losing some of the wind from their sale? Some of the people that crossed the line there in the House to vote for that were doctors, Republican doctors. And I think that's very significant. Exactly, that's right.

I think there's been enough pressure, grassroots pressure on legislators from their constituents and it's been a reflection of their unhappiness with the system that someone will take the time to write or call their legislator. And I think that message is getting across now. What about, when I ask you this, about the unionization of doctors, isn't that also something that HMOs are frightened about? Well, yes. I think they are a little frightened about that. And I'm not sure where that's all going to go. Currently, it's really against the law for doctors to organize. And so there really have to be a change in state laws in order to have doctors organized. But there is a move of foot, obviously. The AMA and the Convention last summer did vote to at least investigate the formation of a union and committees are now being formed to do that. How far that'll go? I don't know. And that's just another symptom of the frustration, if you will, in this satisfaction of physicians in their present situation. Where do you think this backlash is going to lead? Do you think there's a trend now that's going to, I guess, launch or motivate things to

change within the health care system? Well, that's the 6-4-odd questioner. I can just tell you, I was recently at the opening of the Heart Hospital here in Albuquerque. And I can tell you that is a temple to technology. And it's a wonderful facility. It's really mind-boggling the technological facilities that are there. And I think Albuquerque should be very proud to have that kind of facility in the state. Now, there's controversy about the building of it, and I won't get into that. But at least as a facility, it's first rate. And I think you have 55 rooms with individual patient care in each room. You can order meals any time of the day. And it's a very impressive facility. But I'll mention that to say, this is one arm of health care. And then we have the other arm that Senator Feldman just talked about, where you have mentally ill children who can't get care. And these are the spectrum of our medical services as they are today.

Now, where is that all going to come to pass? If I were to speculate, I think that what's going to happen, we're going to eventually reach a universal access program of some type. That's pretty strong, because they can get it. That's pretty strong statement. It's only my opinion. But I think, again, just based on the technological advances of medicine today, and the extreme expenses of those procedures, how are we going to pay for that? And I think we can only pay for that if the risk is spread throughout society. Now what that means is that we're going to have a payroll deduction for our health care. It's just going to be like your Medicare or your income tax deduction every month from your payroll. You're going to have a deduction for health care. Now, there may be different levels. If you're 20 years old and you don't want the platinum plan, you just want catastrophic health care, maybe you get 20 bucks a month deducted. If you're 65 and you're worried about your diabetes and everything else, you may want

to get the top of the plan. So you're saying the managed care system is in transition? Yes, yes, I do. I think so. I don't think it's sufficient enough at this level to really meet the needs of society. And I think that the more dissatisfied people become with the HMO system and the managed care, the more interest they do have in a single payer system, in a universal health care system. And every year in the legislature, the universal health care bill gains a few more proponents. And this year, it got to the floor of the Senate. And I think there will be increasing interest until summer forms are made. So if these issues, the low-medicated reimbursement, the hassle factor of HMOs and the gross receipts tax are not addressed, and we have about two minutes left, what will be the outcome? What do you think will happen in particular in New Mexico? Well, I think you're going to lose some good physicians.

And I think you're going to lose a certain level of patient care that we have in the state now. I would agree. I would agree. I think that we will, of necessity, have to address those issues in the legislature. If we are to go forward without a crisis building in the medical community. And sometimes, when I look at the behavioral health care system, I feel that that crisis is already here. And I do want to remind, or tell our viewers, that I did invite the HMO representatives, the medical directors, but they were not able to make it here today. I want to thank both of you for joining me today. Thank you so much for this information. And hopefully, we can revisit this issue again during the legislature. You will probably be very involved in it as well, right? Well, hopefully, yes. He has to treat patients. Exactly. I'm still working for a living. I'm so practicing every day. I'm so practicing every day. Okay. Thank you both very much. And that's our report for this evening. Join us next week for a discussion on the growing heroin problem in northern New Mexico.

Until then, from all of us at K&M E, I'm R.C. Choppa. Thank you for joining us. Thank you. Thank you very much. You