Trump

Don’t Surrender

flying cadeuciiIndependent physicians are at the beginning of a challenging movement as we fight to stay relevant and solvent during the transition of health care from independence to “regulation without representation”.   In 1773, British Parliament passed the Tea Act with the objective to help the struggling British East India Company survive. Opposition to the Act resulted in the return of delivered tea back to Britain.  Boston left the ships carrying tea in port and on December 16, 1773, colonists in disguise swarmed aboard three tea-laden ships and dumped their cargo into the harbor.  The seeds were planted for the Revolutionary War. 

Physicians in private practice are facing a war of our own, and make no mistake; we are battling for our freedom and our livelihoods.  Insurance companies and government control of health care has become “regulation without representation.”  Lofty guidelines are being imposed, while administrators, insurance executives, and policy consultants are wedged firmly between doctors and patients.  Ironically, when it comes to taking responsibility for a life, the physician is standing there all alone.  How dare we ask a fee-for-the-service we have rendered?  That would be ‘fiscally wasteful’ according to health policy pundits who know nothing of service-oriented occupations.  This is my call to action. 

Where is all the money going?  CEO’s of healthcare insurance companies are making millions. High level CMS employees undoubtedly have higher incomes than primary care physicians.  I do not hear cries of ‘fiscal waste’ when it comes to paying these non-essential members of the health care team.  They are middleman sucking the life out of patients and physicians. The CEO in this story is on the Forbes top 10 list for compensation.  In one year he made $102 million, which amounts to approximately $280,000 a day. Where is the outcry from the media and public?  They jumped all over Mylan when they started charging $600 for an Epi-pen two-pack.  How many Epi-Pens could this guy buy per day with $280,000? 

The majority of physicians are beholden to third party payers, who decide what our work is worth, like modern day indentured servitude.  Instead of having conversations with patients, our time is spent buried in absurd paperwork, endless forms, and questionnaires to accommodate federal requirements instituted by elected officials while industry insiders are controlling the puppet strings.  Physician lobbying groups, such as the American College of Physicians, keep telling us to “roll over and play dead” because they are profiting regardless. 

While they may not be drinking tea, the business of healthcare is certainly having a party at the expense of physicians, patients, and taxpayers.  It is time the party comes to an end.  Physicians are being held accountable for outcomes yet have no influence on how we care for our patients in our own offices.  Medicare beneficiaries are forbidden from entering private contracts with their long-term physicians (DPC); the only way out is physicians must say no to Medicare and some private insurances. 

Last year, a large insurance company and I did not quite see eye to eye.  Family X already had two children for whom I provided medical care.  Their newborn was assigned to an adult nephrologist two counties away by mistake (I hope), so it seemed reasonable to provide necessary primary care for their third child.  This infant had a respiratory arrest at her two week appointment.  I resuscitated the baby and paramedics transported the infant to the children’s hospital for PICU care.  Imagine my surprise 2 months later when a “take-back” was initiated on the payment for this patient encounter after initially being compensated.  Dr. W in the appeal resolutions department told me to “lose his phone number”; he thought a few hundred dollars was too costly for just saving a human life.  Believe it or not, Dr. W was a pediatrician in private practice before “if you can’t beat them, join them” took hold. 

Ultimately, I had no choice but to bill the family for provided services (at a considerable discount) as cash pay and they obliged.  A threatening letter arrived a few days later from Mr. CEO that balance billing was illegal and there would be serious consequences if I insisted on any monetary payment for my work.  This by definition is worse than indentured servitude.  Balance billing is charging a patient the difference between what health insurance reimburses and the provider charged.   The fact I was not paid by his company nullifies his entire accusation. 

I fired off a response humbly suggesting he focus more on placating his stockholders, while leaving the work of saving lives to me.  Our practice cut ties with this company, notified patients it was no longer accepted in our practice, and most families changed their insurance plans.  You would think my David and Goliath-esque tale ends here; however our local federally subsidized Community Health Center is the only place accepting this exchange plan (for reasons that should be obvious at this point.)  There is no pediatrician available.  The tables turned toward negotiation. 

Local insurance representatives inquired why patients were being turned away.  Never having signed a contract, I made it abundantly clear they had no control over anything.  If I did not receive back pay, there would be no further deliberations. Suddenly, ‘take-backs’ were being halted and back payments were being reversed from over a year before.  When a high level executive called to ask if I would reconsider accepting their patients, it dawned on me that physicians may hold more cards than we realize. 

Health policy experts and insurance executives are NOT physicians and they require our expertise; they have not foreseen the complications that will arise when supply does not meet demand.  Physicians are fed up with data collection requirements, cumbersome electronic record systems, and outcome measures that mean next to nothing.  The time has come to throw proverbial tea chests into the Harbor and refuse to comply with the regulations being enforced up on us.  “No Regulation without Representation” should be our battle cry.  My practice is terminating another insurance contract this week.  If we make smart business decisions, refuse to follow the rules while managing to survive long enough, we can win this war.  Patients deserve better.  Physicians deserve better. 

Acquiescent physicians have already been driven out of independence.  Those of us who remain are smart, resilient, capable, and now we must be resolute in our refusal to comply. We know how to provide extraordinary care, which is why our doors are still open.   My office is overwhelmed by patients clamoring for a living, breathing physician who listens, makes eye contact, and is not attached to a computer.  We must never give up, we must continue to argue, irritate, and aggravate healthcare bureaucrats at every turn, like those brave individuals who boldly tossed tea into the Boston Harbor many years ago.  Defiance will inspire progress. Do not surrender at any cost.   

Livongo’s Post Ad Banner 728*90

Categories: Trump, Uncategorized

31
Leave a Reply

9 Comment threads
22 Thread replies
1 Followers
 
Most reacted comment
Hottest comment thread
7 Comment authors
meltootsAllanPeterpjnelsonNiran Al-Agba Recent comment authors
newest oldest most voted
Peter
Member
Peter

I can understand complaints against large institutions (CMS/insurance) as we all have experienced it in some form. I also support PCPs getting higher pay (at the expense of specialists), but the complainers here seem to want it both ways – payments without oversight. Again, no one, not even the “evil” government, is forcing you to be in Medicare or insurance. Go cash, you’ll be able to lower your prices, reduce your staff, and free yourself to practice medicine the way you want, except for professional oversight – if you even want that. I was insured with BCBS once until they… Read more »

Allan
Member
Allan

You took the route of no insurance, but what if the government forced you to pay for that insurance anyway? Would you then forgo use of that insurance? The answer for most is no. They would use Medicare especially since Medicare permits so much usage. You might supplement that with completely private care, but I feel sure most would use Medicare. What does the doctor do with his patients that are on Medicare when he no longer takes insurance? It is pitiful, but those patients then have to pay cash and can no longer keep their doctor without such payment.… Read more »

Peter
Member
Peter

“You took the route of no insurance, but what if the government forced you to pay for that insurance anyway?” If the government did truly single pay coverage with everyone paying through taxes (even Trump) then I would gladly pay. My income did not qualify for an ACA subsidy and I became Medicare age before I had to pay any premium, but for those who do qualify they are signing up. However, the enforcement of the mandate is weak. I gladly pay my Medicare premium. I’ve had no problems as I did with BCBS private. No one’s going to bail… Read more »

Allan
Member
Allan

Peter, I don’t have any problem with what you did, but what would have happened if your health were such that you couldn’t fly to India and the costs were above your means? Would you force them to let you die? If after the hospitalization you were doing perfectly fine but had to remain on dialysis for a limited time and you didn’t have the money, would you permit someone else to pay for you for that limited period of time? Single pay means one entity pays all the bills. Do you have an idea of which model you would… Read more »

Niran Al-Agba
Member

Look, a little oversight is fine, if it makes common sense and actually improves quality of the care being provided. I have written multiple posts on THCB about building better metrics. https://thehealthcareblog.com/blog/2016/08/16/building-better-metrics-invest-in-good-primary-care-and-get-what-you-pay-for/. I am not unwilling to work with the government if it is for the benefit of the people. I (and many others) happen to disagree about what oversight is best and my larger point is we are physicians in actual practices who are out on the front lines. We KNOW what makes care better. For example, why not place a “care coordinator” in each small rural area to… Read more »

Peter
Member
Peter

“For example, why not place a “care coordinator” in each small rural area to help patients get better access? In our town multiple physicians could share that one person and those with chronic illness can get some extra help. That would save money, resources, physicians time, and taxpayers money. These are real solutions for real problems.”

Why wait for the government, especially in rural and small towns. Why can’t the local docs hire a co-ordinator or link computers with patients records. You complain about the government but want the government to take action.

Niran Al-Agba
Member

How do we pay such a person exactly?

Peter
Member
Peter

I don’t know, how do you pay your office staff?

meltoots
Member
meltoots

You are always an inspiration Mommy Doc. Today I lost a battle with CMS. I wanted to see my QRUR (the output for PQRS, VBM, etc) because my registry asked to see it. After essentially 3 hours on the phone from QualityNet, CMS, my bank, Experian, all multiples times,filling out multiple forms, repeating all my IDs and faxing a copy of my passport and 2 bank statements to CMS, I am still unable to download or review it. Yet CMS finds it perfectly appropriate to post that some pharma company paid $3 for a lunch once for me in 2015.… Read more »

Niran Al-Agba
Member

If you ever take a vacation out to the Pacific Northwest, we need to have coffee and commiserate. I am so sorry you are burned out. I will say an occasional win here and there against the “big guys” does keep me in the fight! Glad I could inspire you a bit. I am part of one of the Transformation of Care Grants and the insurance company awarded the grant cannot figure out how to make patient panel lists accurate. They literally have been stumped by my simple question (and a few others) for the last 30 days. The HEDIS… Read more »

Allan
Member
Allan

Thanks for that advice. I googled his name and I would be embarrassed if that were me. One article said it all in a few words “one of the most shameless mop up artists”

Peter
Member
Peter
Niran Al-Agba
Member

Ma’am, let’s just agree to disagree. Whether or not Medicare patients can find primary care physicians in the coming years will tell us who was correct.

Perry
Member
Perry

Don’t worry, we’re going to have “teams” and PAs and NPs. Who needs docs?
(facetiously)

Allan
Member
Allan

“it dawned on me that physicians may hold more cards than we realize. ” We do, but we have to be very careful how these types of things are done. If we remember the Tea Party, we remember that we took the higher road. Later we paid for the tea that was dumped. We have to do things within the law and maintain our dignity and professionality, but that can only occur with physicians thinking in a non-specific proactive fashion rather than after the fact because the government can and has used RICO. Medicare is as bad or worse an… Read more »

Niran Al-Agba
Member

Allan – I am so sorry to hear about your miserable experience. If it is not Medicare, it will the State Board of Health, a large insurer, or whoever else wants a piece. Don’t forget my painfully terrible experience with the Office of Civil Rights about medical records fees found on my blog. You are correct about taking the higher road and it is important to be careful as to how things are done. IMO, things should be done proactively, within legal boundaries. For instance, each contract we terminated (two so far) have notified patients 3-4 months ahead of time… Read more »

Peter
Member
Peter

I can’t understand this, “I’m trapped in the system” POV. There is a solution – go cash only and off the grid. Mr. AL-AGBA, why don’t you do that?

The private PCP is a small business, no more threatened than any other small business. How many small businesses have been destroyed by Big Box Home Improvement and Walmart.

Niran Al-Agba
Member

First and foremost, it is Dr. Al-Agba if you are going to use a title. Niran is fine as I am not super formal, even with my patients. I may seem like I have balls of steel, yet I do not actually have them on my anatomical form. Hope that issue is now clear. Ok there is no trapped in the system for me, but many others are frustrated to the point of retirement or suicide as they see no way out. I am letting them know with fortitude, we can overcome. The sole reason I do not go off… Read more »

Peter
Member
Peter

“First and foremost, it is Dr. Al-Agba if you are going to use a title.” For someone who claims not to be “super formal” you feel quite self important. I’d like a link to some studies of all these doc suicides as a little Goggling showed it highest in medical students. Dentists have a high rate as well, but I never hear much griping from them. My entire life of 65+ years I have heard much griping by docs. A profession usually respected (apparently not as much as nurses), certainly well paid, and for the most part shielded from economic… Read more »

Niran Al-Agba
Member

Miss Peter- I say accuracy, you say self-importance. You obviously do not like physicians and seem like an unhappy woman in general. I do hope you find much happiness as you coast into your golden years.

Peter
Member
Peter

“You obviously do not like physicians and seem like an unhappy woman in general.”

You a assume a lot with no information. Why do you think I’m a women, especially when my name is Peter – sorry, that’s Mr. Peter to you.

Allan
Member
Allan

“you feel quite self-important.” I don’t think Dr. Al-Agba’s statement was one of self-importance. She is describing what she sees so her title M.D. has importance. She wants open dialog and wants to let the listener know where she is coming from. Yet the kind doctor told you that use of her first name was fine as well. It sounds like you own the problem and it has to do with your ego, not hers. “The private PCP is a small business, no more threatened than any other small business. How many small businesses have been destroyed by Big Box… Read more »

Niran Al-Agba
Member

Thank you Allan- agree wholeheartedly.

pjnelson
Member
pjnelson

The paradigm paralysis of our nation’s healthcare industry is generally unyielding. It is good to acknowledge the isolated examples of retrenchment. The fundamental problem for our nation’s healthcare industry is that it is paralyzed by the codependent relationship between the payers of healthcare and the portion of our nation’s healthcare devoted to Complex Healthcare Needs, principally the University based healthcare institutions. This is now severely aggravated by the lack of increased funding of post-graduate medical education by Medicare, for about 4 years now. This has occurred in-spite of the medical school increasing enrollment. Currently, there are medical students who will… Read more »

Niran Al-Agba
Member

Dr. Nelson- how unfortunate. That is my birthday. I will be thinking of you and your colleagues. We have never had a nurse, but if we did, we wouldn’t be able to afford it either. These are sad times.

Niran Al-Agba
Member

Thank you for your support gentlemen. Our fortitude is our greatest strength. It is time to use it!
Medical societies are full of physicians who were not good enough to make it out on the front lines. Of course they are being led by the nose. That does not mean independent docs must follow.

pjnelson
Member
pjnelson

Niran,

Given the degree of professional burn-out among my own colleagues and the financial needs of young physicians, there will soon be essentially no Primary Physicians in private group practice.

The future of our nation’s healthcare industry will become increasingly buffeted by the complexity of payment processes, meaningless EMR systems, rationing and the absence of any connection to solving the under-served needs within every community.

Please don’t give up!

Paul

Niran Al-Agba
Member

I do not plan on giving up. I anticipate being the last independent clinic standing.

Allan
Member
Allan

At one time I planned to be the last standing physician that didn’t accept Medicare in my area (a time when the patient was sent the Medicare check), but eventually I succumbed. I was, however, able to refuse all HMO’s. Later I considered cash, but that meant leaving patients I had treated for decades along with a lack of coverage so I remained chained to Medicare and insurance. My compensation did not lead to significant complaints . I did complain about how these huge organizations maltreated my patients. On occasion I got into fights with those at a very high… Read more »

LeoHolmMD
Member
LeoHolmMD

“Stop punishing doctors, the sick, the elderly, and the poor.”
Thanks for doing what the scoundrals in the medical societies would never do.

Perry
Member
Perry

Don’t Tread On Me!