Dr. Joe Esposito has been a surgeon for nearly two-thirds of his 56 years, and is a member of one of the state's largest privately owned, multispecialty physician groups.
He has one word for state Insurance Commissioner Joel Ario, who in late January is expected to make the final decision concerning the largest insurance deal in state history -- the proposed merger of Pittsburgh's Highmark Inc. and Philadelphia's Independence Blue Cross.
"Don't," approve the deal, he says.
"I don't think having just one health insurer is good for everybody," Esposito said, during a telephone interview from his offices in Wormleysburg, outside of Harrisburg. "Highmark doesn't negotiate; they tell us 'we don't negotiate with physicians.' Competition is good for everybody."
Many physicians and consultants see little good coming from the proposed merger.
Both sides have deluged the state Insurance Department for months with thousands of pages of written testimony, graphs and charts. It was enough paper to cause state Sen. John Pippy, R-Moon, a member of the Senate Banking and Insurance Committee member, to admit a review of data almost is overwhelming.
On Thursday, the Senate committee urged Ario to block the proposed merger by a vote of 10-4. The recommendation is not binding.
Hospitals and physicians, along with the two insurance company's competitors, oppose the merger. Most agree that combining two market share giants into one will lessen competition and in some ways mean cuts in reimbursements. Statewide market share of the new company would range from 53 percent to 72 percent, depending on which consultant's numbers are used.
Highmark recognizes its relationship with care providers is edgy.
"There's a delicate balance, a natural tension between insurers and physicians," said Carey Vinson, Highmark's vice president of quality and medical performance management. "We have to make sure that payments we make are appropriate."
The insurers say the combination gives the new company the size to better compete against much larger for-profit insurers. A merger, they say will allow the new firm to keep insurance affordable, improve health care quality, assure access to quality physicians and hospitals, continue to serve as an in-state economic engine, and make it easier for customers to do business with it.
"There is tremendous fear among physicians in Pennsylvania," said Susanne Madden, president and CEO of the Verdun Group, a physician consulting firm based in Nyack, N.Y. "Physicians in are caught in a Catch-22 situation. They don't want to rock the boat, so they don't do anything. But if they (the insurers) decide to drop a plan, that could wipe out half their practice."
Recent surveys indicate physicians already feel pressured by insurers to alter the way they treat patients. A survey conducted by the Medical Society of the State of New York found that 90 percent of physicians surveyed felt they had to change the way they treated a patient based on insurance company restrictions.
And 87 percent of respondents to the New York survey agreed with the statement that sometimes they are pressured to prescribe a course of treatment based on cost rather than on what may be best for that patient.
In a just-released nationwide survey of some 12,000 physicians by the Physicians Foundation, the impediment ranked highest in terms of delivering patient care was "difficulty with managed care organizations" was selected by 39 percent of respondents.
The Allegheny County and Pennsylvania medical societies both asked for more specifics concerning the merger, agreeing that the merger should not be approved until Highmark and Independence Blue Cross demonstrate tangible benefits to patients, providers and payers.
Reimbursements, pay for work performed, is one of the biggest reasons physicians and insurers are at odds, both groups acknowledge.
"Highmark has a standardized fee schedule statewide which applies to all practice sizes," Highmark spokesman Michael Weinstein said. "We do periodic reviews of payments, and we try our best to maintain remuneration percentage points above the Medicare reimbursement. But there's always the balance between a fair reimbursement and keeping our products affordable."
"Physicians are shut out when it comes to reimbursement rates," said Mark Meade, president of Consulting Underwriters, Chester, Md. "To make up cuts in reimbursement, physicians will attempt to increase utilization, or cut down of their time allocation to individual patients."
"Most physicians would love to spend more time with their patients. Unfortunately, we're not paid for the time we spend with patients, we're paid by the procedures we do," said Dr. Susan J. Kressly, a pediatrician who heads a two-physician practice in the Philadelphia suburb of Warrington. "Our patient visits are often dictated by insurance expectations, which are not always in the patient's best interests."
Kressly added that the proposed Highmark-Independence Blue Cross merger gives her nightmares.
"IBC already an oligopoly in the Greater Philadelphia area, they know they control the majority of patients in the area, and it leaves physicians without any measurable negotiating power," she said. "They have no monetary incentive to work cooperatively with the physicians in the area. If the merger goes through, the oligopoly then begins not only in the Philadelphia area, but across the entire state."
"We don't expect a change in the relationship with physicians following the merger," Highmark's Vinson said. "We will continue to work to maintain quality care and keeping costs to our customers down."
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