Hey there, big, smart, good-looking doctor….
Are you tired of being snubbed at all the parties? Are you tired of those mean old specialists having all of the fun?
I have something for you, something that will make you smile. Just come to me and see what I have for you. Embrace me and I will take away all of the bad things in your life. I am what you dream about. I am what you want. I am yours if you want me….
Seduce: verb [ trans. ]
attract (someone) to a belief or into a course of action that is inadvisable or foolhardy : they should not be seduced into thinking that their success ruled out the possibility of a relapse. See note at tempt .
(From the dictionary on my Mac, which I don’t know how to cite).
If you ever go to a professional meeting for doctors, make sure you spend time on the exhibition floor. What you see there will tell you a lot about our system and why it is in the shape it is. Besides physician recruiters, EMR vendors, and drug company booths, the biggest contingent of booths is that of the ancillary service vendors.
“You can code this as CPT-XYZ and get $200 per procedure!”
“This is billable to Medicare under ICD-ABC.DE and it reimburses $300. That’s a 90% margin for you!”
This is an especially strong temptation for primary care doctors, as our main source of income comes from the patient visit – something that is poorly reimbursed. Just draw a few lab tests, do a few scans, do this, do that, and your income goes up dramatically. The salespeople (usually attractive women, ironically) will give a passing nod to the medical rationale for these procedures, but the pitch is made on one thing: revenue.
Our practice has succeeded despite the fact that we don’t do a lot of procedures. We are in a shrinking minority, and the monthly cash-flow is putting increasing pressure on us to think about “alternative sources of revenue.” Most of my colleagues in private practice have labs, x-ray equipment, or do procedures. Some do such medically vital services as hair removal. I haven’t had the stomach to go that direction…yet.
Who’s at fault for this? Is it the doctors, who are seeking profit over what’s best for the patient? Is it the vendors, who find loopholes in the reimbursement structure to milk extra dollars out of the system?
If you leave meat on the floor, don’t be surprised when your dog eats it.
The payment for the E/M codes (the codes used to bill for doctor’s visits) are low and the payment for CPT codes (the codes used to bill for procedures) are high. This is how our system is set up (with great thanks to the RUC) and it is one of the main reasons we spend so much money on healthcare. We aren’t doing healthcare, we are doing sick care. Healthcare is prevention, which takes face-to-face encounters with the patient. It involves talking and listening, and talking and listening are not deemed valuable by our system. We are paid to do, not to educate or listen.
It takes great resolve to resist this siren’s call. A few years ago, we made a deal with one of the other practices in our building to buy a portion of their x-ray equipment. It seemed to be a good way to make money off of something we do normally in practice. But a few months into this deal, we realized two things:
- We weren’t ordering enough x-rays to be profitable. We had established a mindset of ordering x-rays that minimized their use. It was a nuisance to wait for the reading on an x-ray and it was inconvenient and costly to the patient, so we made most of our judgments based on something else: the physical exam.
- We were ordering a lot more x-rays than we had before. Instead of trying to find reasons to not order x-rays, we were now financially motivated to order them. So if someone hurt their ankle, we were much more likely to order one. If someone had a chronic cough, we were much more likely to order a chest x-ray. The change wasn’t that we were hungry for profit, it was just that we were suddenly 180 degrees from our previous mindset: we were trying to find medical justification to order more x-rays. It was incredibly seductive.
We did back out of the deal, feeling that the care we gave wasn’t better and not liking the fact that we were losing money. But would we have backed out if our practice wasn’t already financially stable? We are a well-run practice that has been successful despite our non-reliance on procedures, but what of the other practices out there that aren’t so successful?
One of my favorite sayings is: your system is perfectly designed to yield the outcome you are currently getting. Nowhere is this more true than in healthcare. We have set up a system that encourages consumption. We pay doctors more to do more. We pay doctors less to spend time with patients. We want our doctors to do better care, but we pay them to do worse care. We want to save money, but we reward those doctors who spend the most.
So why not change? Why not pay more for E/M codes and less for CPT codes? Yes, some doctors will abuse this system by running patients through their office and spending little time with them, but at least it will increase availability of doctors to see patients. There will always be those who take advantage of any system; that shouldn’t stop change.
I went into medicine to take care of people, not spend their money. Why can’t we have a system that doesn’t force me to decide between the two?
Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.
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“Your concerns regarding incentives could be addressed by reimbursing patients who go to non-participating physicians at l0% below the standard Medicare allowance less coinsurance.”
Barry – I agree with your modified scenario 🙂 If insurance (private or public) offers fewer benefits/reimbursements for out-of-network providers, then there is an incentive to be in network. In commercial PPOs, out-of-network benefits are often 20% lower.
But if the payment amount is exactly the same (as in your example) and the timeliness of payment is the same (why would it be different?), it’s hard to see why any provider would elect to stay in network.
Paolo – I disagree.
Doctors who opt out of Medicare would have to collect their charges from patients directly and offer discounts from list on a case by case basis. Patients would have to submit a claim to Medicare to be reimbursed for the Medicare allowance less coinsurance though, as a courtesy, the doctor’s office might submit the claim on the patient’s behalf. Moreover, doctors with a practice consisting mostly of patients from the lower half of the income distribution might be hard pressed to collect from patients on a timely basis and could be much better off participating in Medicare to ensure prompt payment if nothing else. Your concerns regarding incentives could be addressed by reimbursing patients who go to non-participating physicians at l0% below the standard Medicare allowance less coinsurance.
While some doctors opt out of commercial insurance as well, most don’t. I think the same dynamic would work with Medicare and/or Medicare Advantage if they were structured along the lines I suggested.
Barry – if any medical provider could bill Medicare for the same amount, there would be no incentive to be in Medicare’s network. Almost every provider will opt out. This would transform Medicare into a stipend system where all members get a fixed subsidy per procedure and then use it to shop around for medical services. If (and this is a big IF) this is what seniors want, I have no problem with it.
Barry Carol is exactly right. And thank you to Dr Urbach for a supportive statement.
I am here to be constructive. People do not realize that harsh actions are meant to bring about effective endpoints. Striking is outlandish, but, it would get attention of Washington as fast as saying the word “What?!”
And believe me, we would not be striking for long. These are desparate times, and we owe it to patients and our equally invested colleagues to restore order and sanity.
Again, to hell with the business model for this profession! Happy Thanksgiving. And to all going to airports, think about how this is the metaphor for coming federal intrusions into health care as well!
Barry: your last post is exactly what I’m talking about. And if DeterminedMD is still reading this, thank you for a constructive comment. I agree wholeheartedly with you.
Barry,
All of that would take major legislative changes. Current law specifically sets the benefits and caps the plans and cost sharing that can be offered.
I think insurers are very closed minded, they aren’t int he business of underwriting risk anymore. Your idea for a high deductible medicare option makes perfect sense, what about all the people with HSAs prior to 65 who suddently have to drop their consumer driven plan and switch to the most unconsumer plans of all. Not to mention if you have accumulated a sizeable chunk in your HSA you could never spend it down with current Medicare.
If you think about all the waste in Medicare HSAs would be a great first step to fixing that.
All new retirees after 20XX should be giving no choice but a high deductible.
I think the most practical potential solution for the balance billing issue within the Medicare patient population is to allow doctors who do not participate in Medicare to be considered what commercial insurers call out of network providers. While providers who accept Medicare might still have to accept its allowance as full payment, patients who choose to go to a doctor that doesn’t accept Medicare should be able to collect from Medicare what it would have paid if the doctor were in network. So, if the normal charge for a 99213, for example, is $100 and Medicare allows $50 and pays $40 (80% of the allowance with 20% to be paid by the patient), the doctor would be able to collect some or all of the balance from the patient while the patient would not have to pay the entire bill completely out of pocket. To implement this approach, would, of course, require legislation to change the rules. Alternatively, perhaps Medicare Advantage could be allowed to work this way while keeping the current rules for standard Medicare. Changing the rules would be a tough sell on Capitol Hill, however, because of the combination of a “we know best” mentality and that people, especially less educated people, cannot be trusted to act in their own best interest.
Dr Lamberts:
You end this post with this comment:
“I went into medicine to take care of people, not spend their money. Why can’t we have a system that doesn’t force me to decide between the two?”
I do not think they can be mutually exclusive, because unless you want to take a vow of poverty and treat people for the sake of personal satisfaction alone, you have to be paid for providing a service, albeit one that it is hard to put a specific monetary value on it.
So it comes down to the basic premise of any transaction: what will people pay for your service as a health care professional? And that is the point I have been trying to make here for what, a year now of commenting? It should be between you and the payor, which should be the patient, but third party payors are part of the world we practice in now, and that won’t change for the most part, because it is entrenched in the mind set of all involved, and no one really wants to take risks to make change, I mean let’s be honest about this!
And isn’t bargaining about the process? But, do we have a say in what we can charge? No, and that is unacceptable and should be rejected, and rather harshly at this point!
Again, we strike and what, we are all jailed? Don’t think so!
If people were offended by my last comment, while I do apologize with some sincerity, not completely. Too many colleagues are whores and cowards, maybe not the participants at this site, but to knowingly accept these behaviors and make no effort to change things, well, passivity is not excuseable, not in my eyes at least.
So, with the pending health care legislation to take hold, and the majority of physicians basically doing nothing of substance to reject it for what this law is now, I have a right to speak my peace, and that is I abhor the passivity and lack of real advocacy amongst my peers.
This is my last comment at this thread. Happy Thanksgiving.
“Besides, with balance billing, as I’ve said before, there would be a huge market for supplemental insurance, who would most assuredly negotiate usual-and-customary prices.”
Dr. Urbach, isn’t this just a simple reductions of benefits for Medicare people?
The supplemental carrier will be the one deciding how much you get paid.
This doesn’t look or sound like the balance billing Dr. Lamberts had in mind, where people have to bargain for discounts or beg for charity when they go to the doctor (or perhaps bring in some homegrown squash).
Dan – For the last several years, CMS has means tested Part B services by requiring beneficiaries who earn more than $85K (single) or $170K (couple) to pay more than the standard Part B premium of $110.50 per month for those aging into Medicare this year. That standard $110.50 is intended to cover 25% of program costs which implies that the actuarial value of Part B services is currently $442 per month ($110.50/ 0.25). At the high end, both singles and couples who earn above $428K must pay $353.60 per month each for their Part B services or 80% of the program’s estimated cost.
I’ve asked a couple of insurers that I’m in contact with if it would make sense to offer a high deductible network product to address this niche for those who would be willing to forgo participation in the traditional Part B program. I think it would require changes in the legislation to allow them to offer such a product but it probably wouldn’t be worth their effort in any case because they think the addressable market is too small.
Separately, regarding the Part D prescription drug program, I’ve never seen a PD plan that offers a deductible higher than $310 which is the standard deductible this year. Personally, I would be interested in a plan that offered a $2,000 or $2,500 deductible with 25% coinsurance above that with an OOP limit of $5 or $6K and then 100% coverage above that. Again, the market may be too small to be of interest to the major carriers. I just don’t know.
Determined: You miss the point of this post. I am not complaining that the system doesn’t favor physicians in a business model. If I was doing it simply as a business, I would just rack up as many procedure codes as is possible. The business model is not hard, it is just bad. It is bad because it dooms the system and it penalizes those of us who want to practice business HONESTLY. The system encourages a business model that is harmful to its own survival.
By the way, I do not write for THCB. I write for my own blog and they republish that which they like.
Dan – I get your point. I think a reasonable solution/compromise would be to allow some premium MA plans to contract with doctors who opt out of Medicare and pay them above Medicare rates. I don’t know if this requires a change of statutes, regulations, or business practices. But it’s the only way to keep contractual rate protections for all Medicare members, while allowing a few wealthier members to use some of their Medicare dollars to pay for better services. I think this is much more likely to happen than balance billing.
Paolo: I’ve opted out of Medicare. So Medicare Advantage is not applicable to my practice.
Dan – I am not a benefits administrator, nor do I work in the medical sector. I’m just a consumer who knows by experience to never go out of network.
I infer from you lack of response that you don’t take any Medicare Advantage plan. If there really were a huge market for seniors who want to pay extra to access premium doctors, there would be some premium MA plan by now that addresses that market.
In any case, we all know that nothing is going to happen in this area unless the majority of seniors want it.
DeterminedMD: I would love to know what you propose to fix our health care payment system. It would be really helpful if you stopped insulting everyone. I don’t think I’m a coward or a whore. I am interested in what you have to say. I clearly agree that we should not capitulate. What else?
Paolo: you sound like a benefits manager. Is that what you do for a living?
I think your doom-and-gloom scenario is unrealistic. When patients have the opportunity to shop for provider networks, especially Medicare patients, they look for the one that has as many of their doctors on it as possible, or that has their primary care doctor on it, or whomever they are seeing the most (for example their oncologist). Besides, with balance billing, as I’ve said before, there would be a huge market for supplemental insurance, who would most assuredly negotiate usual-and-customary prices. The point is not to milk the public. It is to be able to maintain doctor-patient relationships and provide the best care possible for Medicare patients. That is not currently possible, because Medicare pays under cost in primary care, and it is quickly cutting payments to other physicians as well. It is not responsive to supply and demand. As I’ve said before, it overpays some and underpays others, creating absurdities in the supply of physician services. This has to change. When there is a crisis, it will change. I’m arguing for one of many things we need to do to prevent a crisis.
Dan – the second most important benefit of any health insurance (public or private) is the provider network. This guarantees that the patient will get contracted rates when going to a network provider. I’m not on Medicare, but I would never choose a private health insurance plan without a provider network. I don’t want to have to negotiate every time I go to the doctor. I know the insurer has more market power than me and can get better pricing. And I don’t think I’m the only one. Traditional indemnity health insurance is not in high demand these days.
Allowing any doctor to balance bill Medicare patients is equivalent to not having a provider network for Medicare patients. Unless the provider network is too small or worthless, I honestly can’t imagine many seniors (at least the ones I know) being happy with this.
Btw, do you take Medicare Advantage plans? If yes, can you recommend your ex-patients to join whichever plans you accept? If no, are all the MA plan payments too low?
Yeah, it is confusing when you just capitulate to whatever your payment schedule enforces on you, because you and your colleagues are cowards, and/or whores, and never took a legitimate stand when it was obvious managed care came to be just a profit driven machine, and either a sizeable population of doctors just said, “oh, as long as the patients don’t get hurt” in a clueless, naive fashion, or, more disgustingly, an equally sizeable population of MDs concluded “how can I milk this to stay ahead and feed the cash cow!”
A lot of you know this, as you are probably in one of the two groups! And furthermore, who I am and how I conduct my practice is none of your goddamn business, I gave a disclaimer in a post about three weeks ago, which is the full and complete truth, and if you are just looking for bits to attack and try to disclaim me, just call me an asshole and rally around your base, which is as soulless and deserving of your support!
Hey folks, watching the disgusting display at airports these days? Another example of government gone wild and inattentive, but even moreso, just plain dismissive of the public. You know, the people you are supposed to serve and protect, not as policemen, but as advocates and professionals who took an oath to treat people.
Oh yeah, that got lost after medical school, eh? Did anyone here really attend medical school and listen to mentors and teachers who tried to teach you how to be a doctor, not just a memorizer of medical facts, as much as a cash register or failed activist who embraced a vow of poverty as a true liberal idiot would do!?
It is about moderation. A word vilified in this culture today, but interestingly, not by the majority. I believe there are more people out in America who really believe in compromise and negotiation, but they need leadership, and not to tell them what to do, but reempower them to set limits and kick rigidity and inflexibility to the curb.
Which what is profit driven ideology in the end. Make a buck, and don’t give a f—! Is that a motto doctors should support? THINK ABOUT IT!
And turning to a pure electronic health care system is another nail. Do you enjoy making your own coffins? That is what you are doing, listening and then embracing this failed rhetoric of non professionals dictate the course of health care.
But don’t listen to me, I am a hopeless idealist. And thank you for calling me that if you do. It reinforces my soul.
You know, that thing you dumped at the door when you agreed to managed care, and now federal health care.
By the way, to end on a positive note, Ms G-A does say something reinforcing at least once in a while:
“I don’t think you can have it both ways. If you want to decide what you charge each person, you cannot sign fixed price contracts with payers to ensure adequate volume.”
Well said, Ma’am, and thank you!
“Well, at least I listened to my mentors and did not just bend over and say thank you for what was to follow.”
So, please share with us how you run your practice. Do you pay your staff? Do you bill your patients? Do you look for the lowest costs for supplies?
Honestly, DeterminedMD, everyone is VERY confused about what you are arguing for.
Paolo: It is the wealthy who complain about being forbidden to buy more time with the doctor. The more expensive pre-paid practices take advantage of this situation. Wealthier patients are their customers. However, if a patient does not want to pay a big yearly fee (maybe because the patient only sees the doctor once a year), he/she ends up having to see a doctor in a big hospital-owned group, which many do not like. The current arrangement is all-or-nothing. Either the doctor accepts the paltry Medicare fee, or the doctor has to drop Medicare entirely. The result is a mass movement of Medicare patients to large hospital-owned clinics. I hope that when enough wealthier patients learn how this works, they will be open to improvements, which would benefit them, not just the doctor. At the moment, most patients don’t seem to understand how the government has set the system up. At least that’s my experience.
“What we want is to have some control over our finances.”
Most other people want that too. I don’t think you can have it both ways. If you want to decide what you charge each person, you cannot sign fixed price contracts with payers to ensure adequate volume.
determined to not let this “that’s just the way it is” mindset dumb down and defeat physicians who are willing to fight for the profession.
My mistake is taking this fight to a site that really isn’t really interested in telling readers all the truth per their motto: “Everything you always wanted to know about the health care system; but were afraid to ask.” This blog site is really about “Everything that can be turned into an electronic record and make people a profit margin, and we don’t want you to ask”.
But, readers aren’t really asked to skew from the party line, are they? Yeah, you are right Dr Lamberts, I don’t make sense to you because you run a business, then write a post complaining how it’s unfair the business model quite doesn’t fit into the physicians’ model.
Gee, and that is a surprise.
Well, at least I listened to my mentors and did not just bend over and say thank you for what was to follow.
Face it, listening to the basic bent of this blog site, this profession basically deserves what it is getting. And people don’t have the gonads to admit the mistakes and failures and make tough choices to correct them.
Like, the politicians we elect to allegedly represent us? No, they just resent us, and do it very well these days. And this site will profit from it, no doubt about it.
So, determined to teach who wants to hear the truth. And not afraid to offer, ’cause I ain’t afraid to ask!
Do you care, or just being careless!?
I understand why balance billing is advantageous to the physician. In economic terms, price discrimination allows suppliers to make more money by extracting consumer surplus.
However, I just can’t see how the politically-influential Medicare population as a whole will ever let this happen. I can’t imagine many wealthy seniors wanting to negotiate new price surcharges for every visit. I can’t imagine poor seniors wanting to fill out charity applications for every doctor they see. Realistically, neither party will propose anything like this.
Actually, that is an argument (what goes around comes around) for balance billing. Allow it for only E/M codes. With balance billing, the patient knows what the payment will be from the insurer, and knows they will need to cover the rest. Enabling doctors to put up their charges up front would allow patients to decide if the particular doctor is worth what he or she is charging. That’s how regular business works. Plus, if a patient had a significant financial need, the doctor could discout to accept only the payment from insurance. All businesses do this to some extent (giving discounts for seniors, or those in the armed forces, for example). What we want is to have some control over our finances. When we are forced to accept puny payments or be subject to penalty, it makes folks like DeterminedMD (Not sure what determined about) frustrated to the point of giving up.
I know virtually every patient that walks through the door. Every doctor who’s been in practice for a long time with a stable set of patients does. Specialists who take referrals see many patients who are new to them. Large groups of primary care see many of their colleagues’ patients whom they don’t know. But many of us know most of our patients.
I don’t deny the complexity and difficulty of determining who needs discounts, at least in theory. In practice, if a patient struggles with paying their bills, we become aware of it. We ask them what they are willing and able to pay. We almost always can work something out that is acceptable to both parties. If you demand a system that satisfies government desk-jockies, then it’s harder. I really don’t care what the government thinks about how much of a discount I give poor Mrs. Smith, as long as she and I are both comfortable with it.
There is a world of difference between theory and practice. The great pity for patients and for providers is that the theorists are gaining ever more ability to manipulate what we do in practice, and this has NEVER improved the provision of health care.
@Margalit,
No, the days when “the doctor” knew everybody who walked thru the door are NOT gone. Maybe in most places, but not everywhere. I am privileged to know my patients, their kids, their parents, their grandkids, their aunts and uncles, and often their cousins to the third degree! And no, this is neither exaggeration nor sarcasm. 😉
“I’m told that way back in the old days, prior to the passage of Medicare, virtually all doctors charged on a sliding scale basis. The wealthy banker would pay top dollar while the unemployed person or the poor or elderly widow might pay nothing at all.”
“I’m not sure how doctors verified income back then or how they would do it today.”
Through the IRS Barry. Healthcare should be paid through taxes which privately and fairly judges who can pay, how much, and who cannot. It also exposes everyone to the costs which puts pressure on the system to cut the fat and not hide costs through faceless people denied care.
“The wealthy banker would pay top dollar while the unemployed person or the poor or elderly widow might pay nothing at all. ”
I am not at all comfortable with this “sliding scale” being applied by the physician at his/her discretion. Bargaining or begging for discounts every time you see a doctor is demeaning to both sides, I believe. The days when “the doctor” knew everybody that walked through the door are gone. I am also not aware of any other service that is purchased through this bazaar model.
However, the basic idea of people paying for health care according to their financial ability is a good one, and the only way to accomplish such parity in modern times is to pay for health care through progressive taxation.
Gee, I don’t know, maybe as a profession take a stand and say “F Y”, and strike?
Oh, that is too outrageous and against our oath(there needs to be a sarcasm font!).
Our empathy and compassion continually gets used against us, by those who have no clue what those terms mean, much less practice them. And most of my colleagues equally have no clue how to rebel.
Oh well, game over. For us, and this country!
Business model? BAH!!!!
Dan – I’m told that way back in the old days, prior to the passage of Medicare, virtually all doctors charged on a sliding scale basis. The wealthy banker would pay top dollar while the unemployed person or the poor or elderly widow might pay nothing at all. I’m not sure how doctors verified income back then or how they would do it today. Would you ask to see a tax return or pay stubs if a patient wanted a discount? While the vast majority of doctors might try hard to handle billing and collection in a fair and equitable manner, there might be quite a few others who are less tolerant and quick to engage the services of collection agents when patients don’t pay after a reasonable time. I don’t see a satisfactory solution out there.
It’s hard to see how utilization can be significantly lowered until patients change their attitudes. We need to accept reasonable tort reforms and to stop thinking that everything bad that happens to us in life must be someone else’s fault which we should be compensated for through the litigation system. We need to become more accepting of death when the time comes like people in other first world countries are rather than expect to have our dying process prolonged by wildly expensive drugs and technologies to be paid for by someone else. We also need to learn to care about how much services, tests and procedures cost even when insurance is paying all or most of the bill.
Doctors, for their part, need to engage patients in shared decision making so patients fully understand their options including the risks and benefits of each when considering high cost procedures like expensive surgeries and cancer treatments. If we can start to bring about some reduction in demand for high cost, hospital based procedures, we might find that there is suddenly more money to pay primary care doctors adequately for cognitive and preventive medicine.
I agree that balance billing would be difficult for many people. Forbidding it across the board, however, forces all to be under Medicare price controls, no matter the patient’s wealth or lack of it. I think means testing is an obvious answer to this problem. In my own practice, I would be able to see every Medicare patient if I could balance bill enough of them, and those could be the ones that could afford it. Cost shifting certainly occurs whenever prices are kept artificially low. Right now, the only place the costs can shift are to private insurers. Their premiums are skyrocketing. So why not shift costs to others who can afford it? As long as I am paid enough, I’m happy to bear costs of some charity work. I have no problem using sliding scales, providing some care for free, and almost every one of my colleagues does the same. It’s simply silly that wealthy Medicare patients are provided care for less than cost, with the true costs of their care shifted to someone else. I can assure you that as long as balance billing is illegal for all Medicare patients, and prices are fixed below cost, nobody who refuses to accept new Medicare patients will change their minds, and many more will drop Medicare. Those patients will end up at hospital owned practices, which means that the practices will depend on hospital subsidies to stay open. This just shifts costs to Medicare A, and pushes up harder on private insurance premiums.
I don’t mean to suggest that balance billing will solve all our problems. I don’t think all of our problems will ever be solved. One maneuver has countless unintended consequences. Hundreds of maneuvers made at once creates thousands of unintended consequences. I think stepwise reform is far wiser than what our government proposes to implement over the next few years.
Margalit: regarding the radiology clinic we discussed, I don’t know what all their contractual arrangements are, but I wouldn’t assume that they are all ideal. Maybe they just charge a lot less for cash payments.
Dr. Lamberts and rbar: Of course as an internist, I agree that E/M codes should be paid higher. I just don’t think that price controls for everyone are a good idea. When reimbursements were first designed, they apparently made sense. The problem is that government doesn’t respond to the real world. Increasing E/M codes would help primary care and other E/M practices now. What about the future?
“Being controlled and manipulated by people who do not provide the care, who instead just profit from it, and sucker you into trying to keep up with a model that does not fit the service, that is what medicine has degraded to.”
DeterminedMD: how do you avoid this control and manipulation?
@DeterminedMD,
No, you are not the only one who sees it. Myself and my partners all see it. I cannot speak for anyone else. When I started here at my municipal hospital, I reminded the administrators that their paychecks proceeded from my license. I was hiring them to take care of all the money BS, so I could just practice medicine. They said this was understood. I’ve had no interference from them. Too bad this model can’t be replicated everywhere.
This post typifies what is wrong with medicine, especially from physicians. You all sit here and debate mindless business mechanics, because as a whole the profession has allowed the hijacking of it by business models, and we are not in a comfort zone any more. And the more you allow the assimilation, the less we control, the less we function, and the less we heal.
So, That’s just the way it is? All of you who answer yes, you are pathetic, you are part of the problem, and just sit down and shut up and accept your destiny.
Being controlled and manipulated by people who do not provide the care, who instead just profit from it, and sucker you into trying to keep up with a model that does not fit the service, that is what medicine has degraded to.
And I am the only one seeing this?
I think that the discussion has drifted away from Dr. Lamberts initial suggestion. I think he is right and this is one of the few relatively simple and fixable issues in US health care.
Where do we spend too much money in the US? Drugs (that’s a separate issue and involves value issues as well as the question of negotiation, a tool which the Obama administration gave away in an act of corporate socialism/welfare), end of life care, needless imaging and procedures (angioplasties and laminectomies probably leading).
With regards to the latter items: just pay doctors about as much for procedures as they would be paid for cognitive medicine, with moderate adjustments for expertise and risk (e.g. the neuroophtalmologist may charge more given his additional training, and so does the cardiothoracic surgeon given training and higher level of risk/stress during surgery).
Right now, we are going bankrupt (by we I mean both medicare and nearly unaffordable private insurance) because we grossly overpay scans, sleep studies, injections, back surgeries, all kinds of -tomies. No wonder that there is overuse of all that stuff as it is strongly incentivized. Take the incentives away and only the necessary procedures will be done (except for the defensive stuff – mostly imaging – for which tort reform would be the answer).
I really want to hear the arguments against this obvious, simple and rather fair solution if there are any.
Since most docs in private practice do not own diagnostic equipment and/or centers, ordering tests is already “unhooked” from their income.
For physicians employed by private hospitals, there may be a variety of “hooks” gently encouraging them to order tests that are profitable for the hospital.
A community clinic is the closest you can come to the dreaded “socialized” medicine.
Perhaps work ethic and professional pride is not as easy to maintain when temptation stares you in the face every morning.
The better question, IMHO, is why is that efficient and cheap clinic, Dr. Urbach is writing about, not on every single insurance plan?
And as Rob has clearly pointed out, removing all “fear” of lawsuit would not equate to docs/institutions accepting loss of revenue. Can you hear the doc’s conversation to his wife, “Honey, we’ll have to move to a smaller house because I’m billing half what I used to as there’s no risk of lawsuit any more.”
True enough. Then unhook ordering tests from physician income. I work at a public, community clinic/hospital. I don’t get paid a cent more or less regardless of what I do or don’t order. I don’t get paid on volume (or lack thereof) of patients I see. My only real motivator is my own work ethic and professional pride. And the need to protect myself from lawsuits, ahem. This works for me. I don’t understand why it wouldn’t work for others.
“The argument that allowing balance billing would worsen the situation is incorrect.”
Dan – it depends on how you define the “the situation.” Allowing balance billing would obviously improve your economic situation and the situation of any doctor taking Medicare. It would also probably improve the situation of patients who want more doctor choice and can afford (and don’t mind) being balanced billed.
However, it is certain to worsen the situation of patients who can’t afford being balanced-billed. They may no longer be a able to find a doctor. It is also certain to worsen the amount of money the country spends on health care.
The US government is responsible for more than half of all health care expenses. This gives it huge purchasing power. Allowing balance billing is tantamount to giving up that purchasing power and handing it out to millions of individual consumers. This would naturally lead to an increase in the total health dollars spent on the Medicare population.
“America has price controls as well. That’s why we have to keep fighting over who gets what out of Medicare.”
Dan yes (maybe), but we don’t have billing controls. If you read here people also say the system cost shifts from Medicare to private insurance, another revenue workaround where the higher price is considered the “correct” price. Cost controls would mean the entire system is (negotiated) price controlled. And as Rob has clearly pointed out, removing all “fear” of lawsuit would not equate to docs/institutions accepting loss of revenue. Can you hear the doc’s conversation to his wife, “Honey, we’ll have to move to a smaller house because I’m billing half what I used to as there’s no risk of lawsuit any more.”
Barry, price controls can adjust for high rent districts. You’ll not tame this elephant without more central control (no insult to elephants intended).
Nice stats here: http://theincidentaleconomist.com/wordpress/how-do-we-rate-the-quality-of-the-us-health-care-system-%E2%80%93-technology/
Dan – First, I’m not a doctor and neither are any of my colleagues. I work in the financial world.
I agree that, in theory, different parts of the doctor and hospital sectors could be treated differently with respect to balance billing, but it could still get complicated. For example, my cardiologist is also my PCP. Indeed, about 80% of his practice is primary care. Any consult could include elements of primary care and cardiology. Chest discomfort could be caused by non-cardiac issues from acid reflux to pulled muscles. A 99213 could be cardiac related or not. How could he balance bill for the primary consults only but not the cardiac consults? Aren’t many specialists also certified as internists?
The NYC medical market, I’m told, is like no other in the country. There are lots of doctors in Manhattan from PCP’s to teaching hospital affiliated surgeons and specialists who accept no insurance whatsoever. Indeed, it can be a huge challenge to find a surgeon in certain specialties who takes insurance, either public or private.
Margalit: we do use the free-standing clinic whenever it’s in the patient’s insurance plan.
Barry: You’re description of how supplemental insurance work