Rejecting health insurers

When Christine Monroe, 70, visits Dr. Alan Altman for her yearly gynecological exam, her HMO covers the bill -- except for a small copayment. But this month, at Altman's Brookline office, he delivered bad news: After 28 years as a physician, he was no longer going to do business with insurance companies, and Monroe and his other patients would be responsible for their own bills. He handed Monroe a letter and a price list -- $165 for an annual exam -- and said that as of July 1 he would accept only cash, Visa, and MasterCard. Patients will have to pay on the spot for his services.

He won't accept payments from any insurance companies, which he said are hurting the healthcare system by creating hours of paperwork for doctors and paying them less than their services are worth. While he believes $165 is a fair price for a comprehensive exam, the state's major insurers pay him $86 to $122 -- on top of the small copayment from patients.

"I don't want to be a prisoner of the system anymore," said Altman, who said his income has fallen during the past decade.

Altman's decision is unusual, doctors and healthcare researchers said. But it grows out of a potentially serious problem in the healthcare system about which researchers are gathering a growing body of data: unhappy physicians.

Some unhappy doctors, including a handful in Boston, have started concierge medical practices in which they still accept insurance for basic care including physical exams, X-rays, and lab tests. But they charge patients an annual fee that can run well over $1,000 a year for extras including 24-hour cellphone access, fancy waiting rooms, and same-day appointments. This allows them to see far fewer patients each day but earn more per patient.

Others have canceled all but a few insurance contracts to protest inadequate fees and restrictions on tests they want to order for patients. And doctors in 19 states have filed class action lawsuits against eight national insurers, claiming they unfairly deny payments and are seeking financial settlements.

"Physicians are getting very frustrated with abuses in managed care, and doctors are trying to get very creative and do anything they can to cope," said Dr. Donald Palmisano, president of the American Medical Association, a national lobbying organization for doctors.

In some cases, the doctors' solutions end up costing patients more money, shift the makeup of their practices to more well-heeled patients, and limit the access of patients who are less well off.

Monroe, who lives in Dorchester and sought out Altman eight years ago when she was recovering from breast cancer, said she understood his reasons but was devastated. "He's excellent and I've been through so much and I finally found a doctor," she said. "But I can't afford it."

Altman said he will take 5 to 10 percent of his current patients who can't afford the new fees pro bono, and Monroe hopes she will be one of them. But most of Altman's more than 4,000 active patients, most of whom now pay a $10 or $15 copayment per visit, face a difficult decision: Pay for the visits themselves or find a new gynecologist.

Some patients will be able to pay Altman and then seek their insurer's reimbursement, though the way insurers' rules are set up, these patients will still end up paying a portion of the bill themselves. But Monroe and others who belong to health maintenance organizations, the majority of people covered in Massachusetts, won't have that option because Altman won't be in HMO networks any longer.

Altman is clearly dissatisfied. But it's unclear whether physicians in general are any unhappier than they used to be, said Bruce Landon, assistant professor of healthcare policy at Harvard Medical School. About 18 percent of doctors said they were somewhat or very dissatisfied with their careers in 1997 and 2001, according to a pair of national surveys of 12,000 primary care physicians.

Landon, who coauthored a paper based on the survey published last year in the Journal of the American Medical Association, said doctors in Boston, Phoenix, Newark, and Miami were most unhappy. In Boston, for example, dissatisfaction among physicians rose to 19 percent in 2001 from 14.3 percent in 1997. As managed care has loosened restrictions on patients and doctors, this trend has moderated, Landon believes.

But compensation is still a big bone of contention. Since managed care swept the country in the mid-1990s, most insurers no longer pay doctors a percent of their charges, but instead pay set fees.

"Compared to the incomes of other professionals, lawyers and business people, doctors' salaries haven't even come close to keeping up," Landon said.

Dr. John Fallon, chief physician executive at Blue Cross Blue Shield of Massachusetts, the state's largest insurer, said now that health plans are doing better financially, they're starting to raise doctor fees. Last year Blue Cross gave physicians an average three percent fee increase.

Physicians also are forming negotiating groups that give them more clout to demand higher fees, said Tufts Health Plan chief medical officer Dr. Philip Boulter. Tufts this year is raising physician fees an average 4 percent, about twice as much as in past years. Most health plans now are starting to pay bonuses to doctors who deliver higher quality care.

Doctors like Altman in solo practice, however, can have a harder time because they can't split nurses' salaries and other rising overhead with colleagues.

Dr. Cathleen Hood, 47, recently canceled five managed care contracts because she believed the companies' payment policies encourage doctors to provide substandard care. For example, she said, insurers pay her a total of $160 to $200 if she sees four patients in an hour, but only $85 to $110 if she sees one patient in an hour.

"You don't get rewarded for spending more time, because you're never paid just to talk to and listen to the patient," she said.

Altman, 55, said he also could make more money if he squeezed in more patients -- but he doesn't want to do that.

He did his residency in obstetrics and gynecology at hospitals that are now part of Brigham and Women's Hospital. During the 1980s, Altman gave up delivering babies and developed expertise in menopause, hormone replacement therapy, and midlife sexuality. He now speaks at hospitals and conferences around the country, and two years ago he published a book, "Making Love the Way We Used to . . . or Better: Secrets to Satisfying Midlife Sexuality."

Many of his female patients say they go to him partly because he's easy to talk to about embarrassing issues, and many will stick with him despite the higher fees. Karen Bassett, 58, of Easton, said she would never consider switching doctors. She's been seeing Altman for 21 years, and says he never rushes her through appointments.

Lucienne Davidson, of Wellesley, however, is undecided. "I don't know what I'm going to do," she said. "My problem with it is based both on finances and on principle. But I can't really blame the doctors. What recourse do they have?"

Because Altman's practice consists mostly of office consultations and exams -- lower priced services patients can pay for more easily on their own -- and because of his speaking and book income, Altman can more easily turn his back on insurance than, say, a heart surgeon who charges thousands of dollars for his services. Altman declines to say exactly how much he earns, but he said it's in the neighborhood of $200,000 -- somewhat lower than the national average of $220,000 for obstetricians/gynecologists. About half his income comes from speaking and his book.

Altman is clearly frustrated when he pulls out from a desk drawer a list of payments in December from various insurance companies. Harvard Pilgrim Health Care paid him $108 and $86 for annual exams for two patients, and $104 for an endometrial biopsy on another -- a procedure for which he charges $200. Altman did a menopause consultation on one Tufts Health Plan member and charged $175. He was paid $127. Blue Cross, his secretary said, pays $100 to $125 for an annual exam.

While he earns more than the average American, he said he's not trying to just boost his salary. "I'd like to treat my staff better and to keep up with my rent increases," he said. "It's also a matter of pride in what you do. A doctor one year out of residency gets the same fees I do. You get to a point in life where you want to be paid what you're worth."

Liz Kowalczyk can be reached at kowalczyk@globe.com.