Health insurance mergers are why your doctor is leaving [PODCAST]

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In a lot of towns there is only one health insurer left, and that is starting to show up in patient care. Rita Agarwal is a pediatric anesthesiologist who started asking why colleagues in a specialty she loves are heading for the door. This episode is based on her article “Insurance consolidation is a patient safety problem,” published on KevinMD. She explains why anesthesiology went from a top residency choice to the specialty with the highest intent to leave, and what happens to a team when the people in the room have never worked together. You will hear how a single-payer market leaves a hospital with no room to negotiate, why federal Medicaid cuts hit rural and pediatric hospitals hardest, and what it looks like when patients drive hours for care that used to be down the road. She is candid that most physicians, including her, sat out this fight for years. Press play to hear why she thinks this is unsustainable, and what she is asking physicians to do about it.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome back Rita Agarwal. She’s a pediatric anesthesiologist. Today’s KevinMD article is “Insurance consolidation is a patient safety problem.” Rita, welcome back to the show.

Rita Agarwal: Thank you, Kevin. Thank you so much for having me. I really appreciate it.

Kevin Pho: All right, so we were talking offline. You were on more than five years ago, and for those who don’t remember you, just briefly share your story, and then talk about why you decided to share this particular article on KevinMD.

Rita Agarwal: Sure, yes. My story actually has nothing to do with insurance consolidation at all. I am a pediatric anesthesiologist. I trained at Baylor in Houston and at Children’s Hospital of Colorado. I spent a long time working at Children’s Hospital of Colorado before moving out to California and Stanford. I specialize in both pediatric anesthesia and pediatric pain medicine.

My interest is actually more around those issues, but as I’ve gotten older, and I think this is probably true for a lot of us, I’ve gotten much more interested in things like well-being and wellness. So in the last few years I’ve been looking at things related to what makes people happy at work, what makes people satisfied at work.

One of the things that came up a few months ago was several articles that I thought were really interesting. We’ve noticed over the last few years that anesthesiology has become an increasingly challenging residency to get into, and it’s in fact one of the top residencies in terms of the match now. And yet there have been articles over the last, I would say, three or four years. I think the first article I remember reading on this was from JAMA in 2024, and there was also an article on harassment that came out around that time, showing that anesthesiologists had the highest incidence of intention to leave either medicine or their job.

And I thought, “Wait, what?” I think this is such a great field. I still love my job. I still go to work every day. I’m still one of those people who, I will confess, in my 60s, doesn’t really think about retirement that much. I love what I do, and I would love to keep working as long as I can. So it really got me thinking about what is going on here.

Long story short, there were several articles that I then, sort of coincidentally, started looking at. One was on the whole issue around insurance consolidation and what an incredible impact that is having on practices around the country, both in the hospital and outside. I’ll stop there because that was a lot of information. I just want to see if there are any questions.

Kevin Pho: So whenever people hear about anesthesiology, and I’m sure you know this, it’s one of those specialties that, like you said, a lot of medical students would aspire to, and I’m hearing that now it’s one of the specialties where a lot of physicians have an intent to leave, right? So I certainly want to talk, of course, about the impact of insurance consolidation. But just before we get back to that, from your experience, you’ve been in the field for a while now. You’ve seen medical students all the way through to attending anesthesiologists. What are some of the reasons why you speculate that is?

Rita Agarwal: I think that there is, and again, I know I work in fairyland in some ways in that I work at Stanford, and we have a lot of great resources. But even where I am, we’re feeling increasing outside pressures to do more with less in shorter periods of time. There are constantly people coming in telling us we could be more efficient, we could do this, we could do that. I think that loss of the sense of autonomy to some degree, and being told by outsiders, often people who have no idea what happens in medicine, let alone in the operating room and in anesthesia itself, that sense of loss of autonomy is probably part of it.

And I think behind a lot of that, which I hadn’t realized until reading some of these articles, was both this increasing insurance consolidation and the increased power that insurance companies have to dictate what does and doesn’t happen. Everyone’s heard about pre-authorization issues and concerns around people getting care in a timely manner. I don’t think more people, including myself until I read these articles, had really thought about the impact once you actually do get authorized and get your procedure done, and how that can affect your surgeons, your anesthesiologists, and other people who work with you.

So I think that is the sense of dissatisfaction that perhaps many in my field are starting to feel. We’re working harder, we’re doing more, we’re getting told to do even more, oftentimes with the same or fewer resources, and we’re not getting paid more. In fact, if anything, we’re getting paid less. So I think all of those things combine to create that increased dissatisfaction and unhappiness and that intent to leave. And sometimes it’s not an intent to leave medicine or anesthesia, it’s an intent to leave the current job.

Kevin Pho: So let’s talk specifically about insurance consolidation. Now, tell us exactly what we mean by that, and maybe some examples of what you’re seeing in the field.

Rita Agarwal: So, and I just want to preface this by saying I am not an expert on any of the practice management aspects of this. But there are increasingly bigger and bigger mergers occurring between existing insurance companies, and that has really seemed to have taken off in the last few years. You have smaller insurance companies merging together to create one big insurance company, leaving many markets, particularly mid-size to smaller cities and rural areas, where there’s essentially only one game in town.

And I don’t want to name names, because I don’t know all the details of all of the companies and what they’re doing. But let’s say United, because I know that is a big player in the field. You may only have a choice between United or nothing. And you as a patient, you as a physician, anyone who lives and works in that environment has no choice but to take whatever rates they offer, whatever co-pays you have to pay. So it goes across the board. It impacts both the people providing the care as well as the people who need the care. And if you have no other options, what are you going to do? I don’t think it’s as much of a problem yet in big cities.

And then I think coupled with that, again, particularly for rural areas, and this is really pertinent to my field, and this is part of what got me interested in this, is pediatrics. As you probably know, and as many of your guests probably know, there are some really major changes coming down from the federal government that are really going to cut Medicaid reimbursement to pediatric hospitals, to rural hospitals, to underserved areas.

So now, not only do you maybe only have a choice of one potentially very expensive insurance company who can either provide your care or who reimburses the care, and as a hospital, you have no choice. If insurance company X, and they’re the only game in town, says, “We’re going to pay you pennies on the dollar for this procedure,” what are you going to do if they’re the only game in town? Your other choice is Medicare or Medicaid. And if at the same time all of that is being cut, you as an institution, you as a physician, you as a patient, you’re very much stuck in the middle of all of this.

Kevin Pho: So for those anesthesiologists who choose to leave their current job because of what you’re saying, insurance consolidation, like you said, in big cities it may not be an issue, but in rural areas where there is maybe only one dominant insurance company, they don’t have any other options other than leaving that area. Is that correct?

Rita Agarwal: Yes. And so this is, I’m a big consumer of social media. I will totally admit that right now. And I’m on a lot of different physician groups. And what I hear and see from those, from my colleagues, from talking to friends and colleagues around the country, I’ve been in my field for a very long time. I go to a lot of meetings, I meet a lot of people. There’s an increasing intent to leave.

It’s somewhat of a vague term, but for a lot of people it’s, “I’m leaving my,” in anesthesia, “7:00 to 5:00 plus call job where I often don’t know what time I’m finishing. I can’t plan things with my family. I’m stuck in this job where I’m beholden to other people,” to either going more part-time or to doing locums. And locums has become huge. I mean, every single day now, I don’t know if it’s the same for you and in other fields, but certainly in anesthesia I and most of my colleagues are getting two or three or four emails, texts, and phone calls asking for help in different parts of the country. And it’s often the more rural areas, the smaller towns, that are really desperate for help.

They’re offering a lot more money. They’re often offering more flexibility. They’re offering travel expenses or hotel expenses, an opportunity to try something different. So that is what I’m seeing. I’m seeing a lot of people leaving their corporate, their private practice, their academic positions in whatever area they’re in to try something else. And part-time is big. A lot of people are just saying, “Life is too short. Why am I working so hard and getting paid less? I can back off, give myself a little more flexibility, or I can really give myself flexibility by going to locums or per diem or some other opportunity, and do what I want with my life and my schedule.”

Kevin Pho: So what are the impacts of this trend toward locums and part-time when it comes to patient care in general? How does it affect patients?

Rita Agarwal: You know, I think this is the big unknown, right? I think the concern, at least for me and for others, is that there are a lot of studies that show when you have surgeons and anesthesiologists who work together a lot, oftentimes patient outcomes, especially for bigger surgeries, bigger procedures, and sicker patients, are better, because you have greater trust, greater familiarity, and greater ability to really collaborate well together.

And I should say, it’s the whole team. Anesthesia in particular, more so than most other fields, is truly a team sport. I mean, we’re very dependent on our nurses, our scrub techs, our anesthesia techs, our surgeons, our other proceduralists. So there are great studies that show when those people work a lot together and they have a lot of familiarity, patient outcomes are better.

So you can only assume that the opposite may or may not be true. And again, I don’t want to be in any way derogatory, because I don’t know this to be a fact, but my assumption is that when you’re not familiar, and this happens to me personally when I have to go to a location outside of my core hospital at Stanford, the Lucile Packard Hospital, when I have to go over to the Stanford Hospital, my anxiety is high, my comfort level is low, and I’m really very worried about just the things I take for granted. Where are the drugs I need? How do I call for blood, for example, if I need to transfuse? Who do I get help from?

We try to put lots of backstops and lots of support structures in place to try and minimize complications, but it’s still not the same as doing something in a place where I’m familiar and comfortable. So again, I think the concern is that if you’ve got a lot more people working in more unfamiliar environments, the potential for patient safety issues is much greater.

Kevin Pho: So how are hospitals responding to this? You mentioned things like locums, and a lot of these small hospitals are desperate, as you put it, for any type of help because these anesthesiologists are either leaving their jobs or going part-time. So what options are available to them, and what about the role of nurse anesthetists in terms of their impact on the situation?

Rita Agarwal: So let’s start off by first just saying that overall there is a shortage in general of anesthesia providers everywhere. It is definitely worse in rural and more underserved areas. I am someone, and I’m just again going to say it flat out, I’m someone who believes in the team model. I’ve primarily done anesthesia either by myself, solo, even though I’ve worked in academics my entire career, or supervising residents, fellows, and other trainees. I have worked and do work with nurse anesthetists.

And I just want to mention, since we’re going to mention nurse anesthetists along with certified anesthesiology assistants, I absolutely think that they both have a really important role. I think anesthesiologists have a really important role. I do believe that medical care should be physician-led in general. I recognize that pragmatically that is often not possible.

So, unfortunately, options are very limited, right? I think right now there’s this big scramble of institutions and hospitals trying very hard to do whatever they can, whether it’s bringing in independent CRNAs if they happen to be in a state where nurse anesthetists are allowed to practice without anesthesiology supervision. And I think most people don’t recognize this: Even when you have, quote-unquote, “independent CRNAs,” most of them have to be supervised by a physician. It’s often the surgeon or proceduralist who is actually supervising them, whether that surgeon or proceduralist realizes it, and that’s actually how it’s written into law. There are only a few states where nurses are truly independent.

CAAs, or anesthesiology assistants, always have to be supervised currently, but they can help expand the reach and the care that can be provided. So yes, they definitely have a role in all of these areas.

But I think the bottom line, and part of the reason I wrote this article, is that this is not sustainable. We’re seeing it in California already that smaller hospitals are starting to have to close down because they cannot afford to provide the care, and that creates medical deserts, right? I mean, here we are, California is what, the fourth or fifth, depending on what you read, largest economy in the world. And we have medical deserts where patients are having to travel hours to get just basic medical care, let alone anesthesia, surgery, and other things.

And I also want to be clear, this isn’t just an anesthesiology problem. Obviously, as an anesthesiologist, that’s what I know best, but this is happening in other fields as well. It just happens to be right now that anesthesiology is at the top of that intention to leave list. But we’re definitely not the only ones. So I kind of wrote this as, hopefully, a wake-up call that something has to change. I’m not an expert in this, but this is not a good place for our country to be in, I think. And I’m sure California is not the only place that’s seeing closures of smaller hospitals, rural hospitals, hospitals in underserved areas, and clinics, and basic places where people get basic medical care.

Kevin Pho: So what’s being done on a policy level, and what should be done from a policy standpoint?

Rita Agarwal: So what I know, again, is just based on my involvement with the California Society of Anesthesiologists and the California Medical Association, and as a result also the AMA to some degree. I think there’s continued work and advocacy for improved payment and improved conditions for physicians in particular. I know the physician roles. I don’t really know what’s happening at other levels. But I know there’s this constant back and forth in Congress, both at the national level and then in local states, to get improved resources, improved finances, and improved reimbursement for everybody, not just anesthesiologists, but for surgeons, for emergency room physicians, for primary care physicians. It’s a constant battle, and every year the proposals are to cut, cut, cut from physicians.

I don’t really want to talk about insurance companies because we’re so beholden to them. But I really feel like there has to be change at that level. It makes absolutely no sense that you have insurance CEOs making millions and billions of dollars, and patients and physicians and others really having to pay increasing amounts, or patients having to pay increased amounts for less care, and physicians getting reimbursed less for the same or more work. So there have to be systemic changes.

And then I also do believe the federal government should really be supporting our most vulnerable patients, and that, in my world, includes children, patients in rural areas, and patients in underserved areas. You and I are blessed. We have resources. If our loved one needs care, we’re going to do whatever we can do within reason to get that care for our loved ones. I’m also blessed that I live in Palo Alto. I’m surrounded by medical wealth in so many ways. I can get whatever specialty care I need for my loved ones and for myself. Other places and people are not so lucky. So there has to be systemic change. That’s what I believe.

What is being done, I know it’s often a very lonely fight. I do strongly believe that more people in medicine should be involved in these things, should take a look and understand what is happening, and get involved with their local associations. Again, whatever field they’re in, there’s always a national or state association that is probably working hard behind the scenes to try and make these changes. So my message is, please get involved. Get involved with your state medical association, your individual subspecialty or specialty or primary care associations, and really start advocating for better pay, better reimbursement, and better care for patients as a result.

Kevin Pho: We’re talking to Rita Agarwal. She’s a pediatric anesthesiologist, and today’s KevinMD article is “Insurance consolidation is a patient safety problem.” Rita, let’s end with your take-home messages to the KevinMD audience.

Rita Agarwal: Yeah, I think my take-home message is pretty straightforward and simple. What is happening right now with insurance consolidation and with some of the national cuts in federal funding for medical care is unsustainable, not just for anesthesiologists, not just for surgeons, but for everybody, for all physicians, and as a result, for patients. And that becomes a patient safety problem, because if institutions close or are unable to provide specialty or subspecialty care, patients’ care gets delayed, and that can lead to more complications.

I just really hope that more people will start thinking about getting involved with their local, state, and national societies to really advocate for better insurance coverage, broader insurance coverage, and changes at the national and state levels to try and really get high-quality care for everybody.

Kevin Pho: Rita, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.

Rita Agarwal: Thank you so much for having me.

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