What good are medical groups in CA?

According to my insurance company, Aetna, the medical practices of HMO-accepting doctors are controlled 100% by Medical Groups. They told me that they receive complaints about the medical groups constantly, and that CA is (almost) the only state in the Union to use medical groups. I even spoke with supervisors at Aetna who talk about how bad medicine is for patients in CA because of the medical groups.

From what I can tell, medical groups only get in the way of providing care for patients.

For instance, a doctor gave me a referral to see a dermotologist to find out why the skin on my ankle was blistering and peeling. It took four weeks (from the doctor’s desire to give a referral, for me to receive the referral, and then for me to make and show up at the appointment). By that time, the skin damage was mostly healed, and the derm could not tell me why it was blistering and peeling. Was this from frostbite? A spider bite? An infection? Something else? No clue. If the referral system was faster, he would have been able to provide a diagnosis.

Another doctor told me he wants me to get a bone scan on my ankle. This is on Monday last week. I am to just sit patiently and wait for a referral to come in the mail. It’s now Thursday of the NEXT week, and I have no referral. Meanwhile, I’m in pain every day, and I am paying my insurance company for my medical insurance every week from my paycheck. And I’m not getting care.

My ankle has been a pain and a problem for 4 months, but due to the medical group lagging providing referrals, it’s often 2-3 weeks (and sometimes 4 weeks) between appointments. Again, meanwhile, I’m stilll in pain every day, and my condition seems like it’s getting worse every day.

These medical groups seem to radically increase the cost of my insurance (we have an office in Arizona, and their insurance costs a fraction of what ours costs) and only lowers the level of care patients receive (our employees in Arizona don’t get the run around we get in CA).

Is it just me? No, everyone I know in CA who has gone through HMO has the exact same difficulties. Doctors do not want to give a diagnosis or prognosis on the first visit, will schedule you for several visits so they can get more money from your insurance company (and your $20 copayments).

So - what “good” does the medical group actually do? Why are they here? Why can’t my doctor just refer me to the correct specialist without some other company getting in the way? Why did the medical system stop caring about providing care for patients, and just making money off of us?

IMHO - I would be somewhat skeptical about an insurance company’s opinion of medical groups (or doctors). They are in a fundamentally advesarial relationship.

It is possible that the delays you are experiencing are because the medical group must get approval from the insurance company to make the referral. In that case the medical group is not the culprit.

I don’t pretend to know all of the ins-and-outs, but I do know that there are a lot of ins-and-outs that they (insurance companies and doctors/medical groups) don’t really want us to know about.

Has the OP considered filing a grievance?

Can you tell us a little more about what you’re talking about as far as a 'Medical Group"? I’m not familiar with the way these things are set up in California.

Medical groups have become quite popular in California, though there are private practice doctors as well. A lot of the reason is quite simply the cost of doing business. Medical malpractice insurance is astronomically high (one doctor can have premiums over $100,000 a year or more for some specialities), doctors are making less then they were 10 years ago, rent is super high, as well as other factors make it so many just can’t afford to stay in business without joining a medical group.

If you don’t like the medical group you’re with, is there another? Or if you don’t like the HMO method, is there a PPO option?

Now you know someone that hasn’t been through that. I always get my referral directly from my doctor, the day that I’m in his office. If they do tests, I normally don’t have to go for another visit because I can check my test results on a secure website. Not all groups have the problems the one you belong to does.

Also known as an IPA, “Independent Physician’s Association”

They receive a set amount of funds from the insurance company for each member assigned to them. Their member physicians are then paid out of that pool, when member’s actually receive services. If member’s use too many services, or the IPA has negotiated a capitation rate that is too low, they run the risk of bankruptcy.

Specialists can also be paid out of this capitation funding, if the IPA has accepted responsibility for such claims.

But that will all depend on the contract the IPA has negotiated with the insurance company. Some IPAs will be responsible for professional fees (physicians’ claims), hospital stays (not very often), DME (durable medical equipment), and any other number of potential submitted claims.

(used to work in the claims department for Blue Shield of CA).

Since it’s a contractual thing, there’s no set template, and specifics will vary from IPA to IPA, and even different insurance companies contracted to the same IPA.

Aetna may have some truth to their claims, but also keep in mind that it removes some level of decision making from the insurance companies (which obviously they do not like) and places it in the hands of doctors.

In general, referrals will be approved if medically necessary. If a referral has been delayed, the member can ask that insurance company expedite a grievance to move the referral decision up sooner. But the first level of this process is to determine if the referral meets “expedited” criteria, which will again vary from carrier to carrier.

The medical group explained that they can do nothing to expedite a referral, that a referral is 100% in the hands of the medical group.
I was told this by two operators, and one supervisor, at Aetna.

When I’m at a doctor’s appointment, and I know I will need to see that doctor again soon, I always try to make my appointment before I leave the first appointment. When they are referring me to another doctor, I ask for that other doctor’s name so I can make my appointment now, rather than waiting for the referral. They always respond that it’s not up to them what doctor I get sent to, it’s up to the medical group to make that decision, and that there’s nothing they (the doctor’s office) can do to expedite it, it’s completely and 100% in the hands of the medical group.
I’ve been told this by a podiatrist, an orthopedic surgeon, and a foot-and-ankle orthopedist. I assume they’re correct, because this is the only thing I’ve ever gotten three separate doctors to agree on.

Our HMO is fairly cheap (like $7 a week) but the PPO is hideously expensive (like 10 times that cost). If I change medical groups, I essentially have to “start over” getting my ankle diagnosed. It’s been 4+ months already (due to all of the referrals and the medical groups).

I filed a complaint against the medical group with Aetna several weeks ago. I filed another complaint against the medical group with Aetna last week. I filed a complaint with the medical group because they messed up when they referred me once, they sent me to a wrong doctor type (ortho surgeon instead of podiatrist, and ortho surgeon couldn’t help me). So far, the complaints with Aetna have gotten no results (certainly not a faster referral system). The complaint with the medical group (which was to recoup the $20 copay on the wrong referral) got the complaint delivered to the wrong doctor’s office (the complaint went to the wrong doctor type, to a doctor I had not yet seen!)

Aetna has stated that they cannot do anything to encourage the medical group to move faster, get me a referral, or anything else. All Aetna does is billing. They were happy to take two complaints about the medical group, but nothing else.

You may want to evaluate your options with the California Department of Managed Health Care. Aetna should provide you with the opportunity to escalate the grievance to the State once they have rendered a final decision. If they closed the grievance, stating it was out of their hands, then the next step is definitely the DMHC.

Regardless, it can’t hurt to contact the State and get the ball rolling on having them look into the matter.

And as for Aetna, there should be guidelines and inventives/penalties for referral turnaround stipulated in their contract with the medical group. Aetna is your insurance carrier and ultimately it is their responsibility to ensure care is delivered within the terms of the policy.

Sorry you’ve had to go through this. My response was more to let you know that it isn’t always like that.

Not to sound callous, but premium price shouldn’t be your primary consideration. (I sell group health insurance and would tell anyone the same thing. The cheapest option is rarely the best choice for anyone)

I notice you’re from Studio City. That’s not all that far from where I live and work (Chatsworth and Simi Valley). Can you recommend a good medical group in the area? I’m currently with Community Medical Group of the West Valley, the one located on Medical Center Drive. I like my current PCP (Mohammed Imran Iqbal) but feel like the doctors are constantly roadblocked by the medical group.

I have a friend in that area that has gone to the same group for 20 odd years and loves them. I’ll double check the name with her and send you a PM. I think it’s in Granada Hills, but I don’t recall for sure.

If it’s Greater Valley or Healthcare Partners, then I’d advise anyone to steer clear of them. My parents have had Greater Valley for years and we are on a first name basis with their site administrators because of the problems their staff create. If it’s Facey, then you might do OK.

FWIW, it took an HMO doctor about 35 minutes to perform a physical on me. When I switched to PPO, it took 90 minutes, plus 15 minutes for an interview on my lifestyle before going into the exam room.

Facey sounds right, but we haven’t talked about it in a long time so I’m not certain.

$280 a month ( 10x what you are paying now ) is not hideously expensive in medical insurance world, it is dirt cheap, even for a group policy. Mine runs about $500 a month for a single person and that is the cheapest policy our company’s insurance agent can find.

I don’t want to hijack, but noticed the word capitation in IAmNotSpartacus’s post, and I’m a little unclear on what capitation means. I’m guessing that it means that the Group has contracted with the Insurance to provide X-type service to Y-number of insured persons. The contract for the Group is based on a guess of what percentage of the insured persons will need care in a given period of time. The Group then gets a monthly set payment per insured person (per capita) assigned to the Group. If the Group spends less than the contracted amount in services for the month, they are ahead. If they spend more, they eat the cost.

Is that correct? Because that would mean that a Group that’s stuck with a costly contract would have an incentive to slow the provision of medical care. Of course they’d be fools if the contract didn’t include a mechanism for adjusting the per capita rate if they could prove that the per capita true costs were substantially higher than expected. So it shouldn’t be that much of an incentive.

I can’t believe that Aetna is saying they’re just a billing service. Unless they are being contracted to bill for another insurance company and that company is the one SeanArenas has his policy with. For my policy, the billing company is Zenith, but the policy is actually with Blue Shield. Complaining to Zenith about anything but billing wouldn’t get me anything. If it’s Aetna’s policy, though, I don’t understand the hand-off policy while the Group violates its contract with Aetna.

You’ve got a good grasp on the basics. Capitation is basically an established rate that the insurance company pays the medical group per member per month that they have them on their panel. One of the main criticisms of the capitation system is that it provides an incentive to give less care, often in the form of not wanting to do tests.

I’m not saying everyone would do that, but it has happened too many times. It’s one of the reasons that I’m not a fan of the capitation system.

Our rates are changing on 9/1/08, and the HMO plan is getting significantly more expensive, so the difference between them won’t be as great after this. My HMO will be $53.01/mo., and PPO will be $214.52/mo. (That’s $12.23/wk and $49.50/wk.)

As to whether or not a particular amount is expensive is solely up to the comparison of the deduction to the paycheck amount. An amount that may not seem expensive to one person might seem expensive to another person because of their general pay difference. It’s not like people who get a lower salary pay less for insurance (as with a graduated tax scale). So, sorry if $214.52/mo seems less affordable to me than $53.01/mo (or compared to $30/mo like I’m paying now).

But it’s not like I can switch to a PPO at will - I can only do that once a year during Open Enrollment (so I can wait until June next year, when my ankle may be better, or have fallen off). Meanwhile, I’m just trying to get a modicum of care, and can’t even get that. Every week that I spend not exercising is another week that my body adapts to not exercising. If/when I get well again, and am able to re-start exercising, these last 5 months of relative inactivity will work very much against me.

I don’t think that it should take any patient 4+ months to receive a form of treatment for an injury which causes pain on a daily basis.

Also, since this thread started and I was able to read some of your comments, I called my medical group and Aetna again to try to get more action. I called the medical group, asked the person who answered if I’m talking to the right people – I want to talk about my referrals, and I’m the patient. She said yes. I said ok, look, the referrals aren’t going very well for me. I’ve been waiting a week and a half for this current referral, and in general they’ve taken about two weeks, and this is too long for me to receive care.

She replies, “You know, I’ve got about a thousand callers on hold right now, and I don’t have time for a call like this.”

Aghast at such treatment, I asked for her supervisor and her name. She transferred me without giving me her name to someone’s voicemail! So I called Aetna.

Aetna offered to change my medical group to another group, but is completely unable to do anything to expedite referrals or treatment. The guy even said, “I really wish there was something more I could tell you or something more I could do, but in California, it’s all in the hands of the medical groups.” He told me that the care I’m receiving is abominable, and offered several times to change medical groups. I told him I would look in to the other groups and get back to them.

I saw my doctor for a physical today – he was aware of about 2/3 of the actions of the specialist, and had no clue about other things. When I asked him about the referral, he said there’s nothing he can do, it’s in the hands of the medical group, and he can’t make it go any faster. He said to just wait for the referral like I was told.

So, although I have been to my primary doctor and four specialists, paid $180 in copays (9 appointments at $20 each) plus over $100 in other payments (for x-rays, crutches which are too small for me and I can’t use, blood tests, etc.), not to mention the money they yank from my paycheck every week … and I have received no prognosis, no diagnosis, no prescriptions, and no physical therapy, and no treatment plans. I.e., we’re still in the diagnostic stage over FOUR MONTHS LATER. Why is it so hard for doctors to provide care for patients?

By the way, I’ll be happy to upload my MRI report (and the whole MRI) if someone can give me a more straight answer than I’ve gotten from the doctors. So far, three doctors who look at the MRI report give me three different responses. One says the 5mm free-floating chunk of bone in my ankle is gigantic and should be removed immediately. Another doctor says it’s tiny and nothing to worry about. Another one says the placement causes him worry, and he’d like to keep an eye on it. How come when three doctors look at the exact same medical report, they don’t reach at least similar conclusions – they’re all over the place?

Oh and the MRI report lists four separate issues:

  1. Longitudinal partial intrasubstance tear of the Achilles tendon associated with minimal inflammatory changes with the pre-Achilles fat pad.
  2. Small area of plantar fibromatosis involving the medial bundle of the plantar aponeurosis at the level of the sustentaculum tali and without significant inflammatory changes.
  3. Old avulsion fracture involving the medial malleolus associated with old complete tear of the anterior taolfibular ligament.
  4. Possible 5mm intraarticular body located in the posterior recess of the posterior subtalar joint.

So from reading this, all doctors have done is refer me on. I went from PCP to ortho surgeon to podiatrist to foot-and-ankle orthopedist, and a dermatologist.

Just something to keep in mind, we aren’t allowed to give medical advice.

Sorry to hear you’re going through this, it really sucks. I would be getting in touch with the insurance commissioners office if I were you. The website is insurance.ca.gov.

When you say “we,” do you mean on this board in general, or are you specifically restricted?

If you meant this board in general, then oops.