His office is filled with antique eye charts and dark wood examining tables. There's a box of lollipops for the kids on their way out the door.
Once he trudged through a snowstorm in the middle of the night to help deliver a patient's baby. He gives a 20 percent discount to patients paying out of pocket.
Past the blue bucket of toys and the old-fashioned rocking chairs are examining rooms that are warm and charming, not cold and sterile. He's the only primary care doctor in all of rural East Haddam. And he still makes occasional house calls.
Dr. Malcolm Gourlie, 60, a kindly physician with a white beard and woolly eyebrows, is the kind of family doctor you see in Norman Rockwell paintings, the kind you'd want in your network if you were a big insurance company like Aetna. In fact, Gourlie is part of Aetna's network, one of only a handful of doctors signed up to serve low- and middle-income families enrolled in the state's HUSKY and Charter Oak health plans.
There's just one problem: HUSKY and Charter Oak don't pay Gourlie enough to cover his costs. He's actually paying out of his own pocket, and losing money, to see patients because the fee schedule negotiated by Aetna and the state is so pitifully low.
"We're on the floor with a boot to our neck, just in terms of our survival," Gourlie says. "That's how I feel right now."
The number of doctors joining the Charter Oak and re-launched HUSKY health programs is growing, but it's still sparse. Some of the largest hospitals and physician groups in the state have yet to sign up. Many say they'd lose money if they did.
In Middlesex County, the first county to transition to HUSKY under new insurance companies, one insurer has just one pediatrician in its network, while another has just six. Neither has the one hospital in the county. Hanging in the balance is the welfare of 338,000 HUSKY patients and thousands on Charter Oak who may have good health care on paper, but find it impossible to actually get in to see a doctor.*
For a state that's home to the insurance capital of the world, Connecticut has a disturbingly high number of uninsured residents, in excess of 300,000. The state's health care crisis is real, and sweeping solutions are in short supply. Gov. Jodi Rell's fix is the Charter Oak Health Plan, which gives adults—regardless of age, income or medical history—bare bones insurance for $259 a month or less. Charter Oak is funded with $11 million from the state and expects to serve up to 19,000 people who earn too much to qualify for Medicaid, but too little to afford out-of-pocket insurance.
So far Charter Oak is doing little to ease the health care crisis. While doctors are struggling through low reimbursements, the insurance companies are making out: They have built 11 percent profits into their projections, double the norm.
Even the best intentioned doctors, like Gourlie, can't afford to participate, casting doubt on whether the state will ever land enough physicians to make the program viable.
This year, the state combined HUSKY, Connecticut's Medicaid program, with the new Charter Oak plan, figuring that only combining the two would produce profits large enough to make running Charter Oak worthwhile for the insurance companies. Three insurance companies were selected to run the programs: one that already served HUSKY patients, and two that did not and had to assemble physician networks from scratch. Building those networks has been a slow and sometimes painful process, as doctors balk at the rock-bottom pay scale.
Health care advocates and lawmakers have pushed the Rell administration to slow down or freeze enrollment until enough doctors are in place to handle the expected crush of patients. But the governor is forging ahead, saying that people are already getting services under the new plans and to freeze it now would deny health care to those who need it.
The Gourlies were among the first practices in Middlesex County to sign up for Charter Oak when it was announced. Pam says they wanted to do it because they're "altruistic by nature. We treat people in our community because they are our patients and times are tough for everybody," she says.
Before long the phone was ringing off the hook with new Charter Oak patients seeking appointments. The Gourlies, who ordinarily treat patients from East Haddam and contiguous towns, were getting calls from as far away as New London, a 35-mile drive. The Gourlies wanted to help out, but not at the expense of their lifelong patients, so they turned down dozens of the requests in those early days.
Dr. Gourlie calls Charter Oak a "really good program" but says it's been awfully disorganized. Information about reimbursement rates, what services were covered, patient IDs and eligibility lists were still unavailable weeks after the programs kicked off. "The information wasn't there and we didn't know where to look," Dr. Gourlie says.
Gourlie grew so frustrated in the programs' opening weeks he drafted a termination letter to Aetna and was ready to bail out, until a company higher-up called him and personally asked him to reconsider. Gourlie's staying in for now, but isn't sure how much longer he can work for no pay.*
Gourlie has cared for generations of families in the village of Moodus, a section of East Haddam. Eight thousand people live here and Gourlie is the sole remaining family doctor. A few years ago his practice had three doctors, plus a physician's assistant. The two doctors moved on to other opportunities. The physician's assistant recently left for a job at Hartford Hospital that pays $15,000 more.
The practice is a true mom-and-pop operation: Gourlie sees the patients, his wife Pam runs the office, along with five office assistants. Gourlie's father was a family doctor in Enfield, and Gourlie still uses his father's medical bag and his big wooden desk. Inside his modest office, Gourlie practices a type of medicine that's increasingly rare in today's managed care world: treating a person's soul as much as their symptoms. Under Charter Oak, Gourlie says, that will be hard, if not impossible, to do.
The problem is this: Say a patient comes in for a sprained ankle but during the course of the visit you learn she is depressed or grieving for a lost loved one. Under the old system, the doctor could treat the patient however he saw fit, be it medication, informal counseling, or just talking it through.
Under Charter Oak, mental health has been "carved out" in order to keep the premiums low, meaning it's not covered. Now when a doctor learns a patient is depressed, he must stop the visit, call the insurance company, verify policy details and send the patient out the door to another service.
Depression is alarmingly common in primary care: Gourlie says he writes more prescriptions for depression and anxiety than almost anything else. Prescriptions reflect the patient population. And there aren't enough mental health professionals available to meet the demand for services, Gourlie says.
"Carving out basic mental health care is a fundamental failure to understand how primary care works," Gourlie says.
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