Surgeons Cut Insurer Loose Most Of Spokane’S Orthopedic Surgeons Quit Msc/Premera Blue Cross

Nearly three-quarters of Spokane’s orthopedic surgeons have canceled their contracts with the region’s largest health insurance company, saying they can’t afford the bureaucratic snarls and low reimbursement.

Several general surgeons and a large radiology clinic also have told MSC/ Premera Blue Cross they plan to end their agreements with the insurance company.

That means about 95,000 people covered by MSC/Premera will pay more out of pocket to have their current orthopedic doctor set broken bones or operate on bum knees.

And if the impasse spreads, the same could apply to people needing other types of surgery, X-rays or ultrasound.

Orthopedic patients also could switch to one of a dozen specialists still doing business as a “preferred” MSC/Premera physician, switch health insurance companies or try to wait out the dispute.

Emergency room visits are not affected by the impasse. People who are in the midst of care - such as follow-up treatment for recent surgeries - also are not affected.

People on three of the 10 MSC/Premera plans - MSC Classic Care, MSC Care and MSC Prime Care - are untouched by the dispute.

But with 28 of Spokane’s 40 orthopedic surgeons canceling their contracts, patients are fuming - at the insurance company.

Tess Clowe heard of the dispute last week when she learned her son, Tyree, needed surgery. She can’t afford the extra expense - as much as 50 percent more - to have their surgeon reattach the University of Idaho football player’s shoulder muscles, she said.

“It’s really hard for us to face going to somebody new who doesn’t know his condition,” Clowe said. “It’s serious surgery. I want to have it done once and done correctly.”

In its defense, MSC/Premera said 800 area physicians accepted the new reimbursement rates proposed last spring. Still, the company wants to come to terms with the other doctors.

“We do hope to continue our relationship with these physicians, and we are currently re-evaluating our reimbursement rates for all physicians,” said Clara Webb Kinner, MSC/Premera’s vice president of communications. “We have to balance access to care, quality and cost as well as balancing member needs and physician needs.”

The Washington insurance commissioner’s office is checking out complaints that MSC/Premera can no longer provide access to enough orthopedic specialists.

“You have to be able to provide the level of care you promise when you sell them insurance,” commission spokesman Jim Stevenson said.

MSC/Premera says it’s still exceeding national and industry standards for the number of orthopedic specialists available to its patients.

The disagreement began last summer when orthopedic surgeons learned that MSC/Premera was again cutting payments for most surgery. Doctors worry that if they settle for less with MSC/Premera, other insurers also will cut reimbursements.

Orthopedic surgeon Dr. Alex Verhoogen said he would have received 25 percent less under the new reimbursement contract. “They keep ratcheting it down and down and down. It’s getting to the point I can hardly afford to see MSC patients,” he said.

And while his reimbursement drops, his medical practice pays higher health insurance premiums for its employees.

“Everybody’s premiums keep going up, all of the doctor and hospital payments keep going down,” Verhoogen said. “Where’s the money going?”

Dr. Arnold Peterson, another orthopedic surgeon, said MSC/Premera offered his clinic 20 percent less than other types of surgeons in Spokane.

“I think MSC is doing the best they can - they only have a certain amount of money,” Peterson said. Still, “I can’t work for what they’ve offered and provide quality care.”

Doctors and other health care providers say money is only one issue. Insurance companies also keep adding bureaucratic hoops.

Verhoogen’s secretary used to make one telephone call for insurance approval for a surgery. Now she calls one number to approve the surgery, another number to authorize a post-operative brace, another to OK physical therapy and another to approve the post-operation MRI scan.

Other clinics, including Inland Orthopedics of Spokane, complain MSC/Premera didn’t even try to negotiate.

Inland Orthopedic office manager Mary Anne Vercic said she left several messages with MSC/Premera over the summer.

“We really expected resolution, but they didn’t even call us back,” Vercic said. MSC/Premera finally called Sept. 30, the day the contract expired, and asked for an extension. “By then, it was too late,” Vercic said.

Kinner, of MSC/Premera, says the company didn’t ignore the doctors. The general manager and other insurance company representatives met personally with 23 of the 28 orthopedic surgeons.

The declining rates, she said, mirror the lower reimbursements being made by Medicare and other federal agencies.

Other specialists are still negotiating with MSC/Premera before their contracts end. Inland Imaging, a large radiology clinic, is meeting with MSC/Premera representatives weekly, CEO Steve Duvoisin said.

Patients and their families are nervous. Clowe met with several insurance brokers Wednesday who told her they see the dispute between doctors and insurers getting worse, she said.

Her husband’s asthma specialist left the state recently, citing insurance company hassles, Clowe said. “In less than a month’s time, two major blows. Who knows what’s going to happen tomorrow.”

Ken Olsen can be reached at 459-5148 or by e-mail at keno@spokesman.com.