August 21st, 2013

Insurance re-write has consequences

As the first state in the country to attempt to institute a government-funded universal health care plan, Vermont will have all eyes on it as the rest of the nation watches how details of their health care reform will be ironed out.

The passing of Act 48 in 2011 led to the creation of a state-funded, independent insurance board, the Green Mountain Care Board (GMCB), which will oversee all aspects of health care reform including the implementation of universal coverage for all Vermonters.

As with any massive change, the effects of re-writing an entire insurance system will have major consequences, some of which have not yet been resolved. How the system will be paid for is one and how rates will be set for practitioners is another.

The new law could even affect providers who do not accept insurance at all, since the act gives the GMCB the authority to set rates for all health care services in the state.

“This act has tremendous importance for solo practitioners,” says Robert Emmons, M.D., a psychiatrist with a private fee-for-service practice in Burlington.

For himself, Emmons has chosen to operate outside of a system that he feels is unethical since, by setting pay rates for practitioners, insurance companies have a direct impact on treatment decisions that should be made primarily between doctor and patient. While he does not feel that others should be forced to follow his business model, he also does not believe the state should have any authority over his rates.

A bill Emmons wrote was introduced by Rep. Cynthia Browning (D-Arlington) earlier this year that would have removed that authority. The amendment was voted down because, according to Emmons, legislators claimed that it would allow niche practices to charge exorbitant rates and possibly sink the whole system, a situation not feasible in a free market economy, he adds.

“My rates are currently at about 50 percent of Fletcher Allen Health Care,” he says. “My practice works. I have no waiting line. I provide high-quality individualized care. I donate 20 percent of my time to my neighbors in need. Patients can choose to see me as long as they want to and they will self-regulate their care according to the cost. We need to have options like this out there.”

According to Robin Lunge, director of health care reform for Vermont, the right to set rates will not necessarily ever be exercised by the board.

“The board may accept that argument. Health care reform is not about making the health care system worse,” she says. “Act 48 does provide the board with the authority to establish rates but the legislation was conceived to provide consumer protection.”

Michael Donofrio, Esq., general counsel for the GMCB explains that the board does have oversight built in on any decisions it makes.

“The board has not yet begun to exercise this authority and would not do so unless and until it went through an open, public process of vetting approaches and seeking and reviewing input from Vermonters and stakeholders,” he says.

As private practitioners, there may be many psychologists who will be affected by rate setting if it ever comes to pass. For this reason, Rick Barnett, Psy.D., LADC and president of the Vermont Psychological Association, encourages psychologists to keep updated on the situation and to get involved in advocacy.

“The law does give the GMCB a number of rights. We are not thinking that they plan to use them to regulate outside of the system but we need to be mindful of that,” Barnett says. “We are working hard to be a part of the process and to have an influence on how it shapes up.”

By Catherine Robertson Souter

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