PookieMD's Blog: Where Physicians Learn About the Business of Medicine

Why do I hate health insurance companies?

Because of threatening letters they send.  My Tweenage Daughter broke her arm, and was treated last November.  Humana, our health insurance, sent me a letter with the following statement in bold letters: “Your timely cooperation in furnishing this information is crucial to administration of your plan benefits.”  And then “we must talk with you immediately about the injury or illness that required treatment as shown on the treatment date…If we do not hear from you with ten days, we will refer this matter for appropriate action.” 

So I call them up.  The insurance company wanted to know if we had filed a claim with anyone else.  Like who? I asked.  Another insurance company.  Aha! The purpose of the call was to see if they could foist the bill on to another company! Then the dude on the line asked, “What caused the accident?” “Gravity,” I answered.  “The force of gravity caused her to to fall after she tripped.”

He was not impressed.  I didn’t dare ask what “appropriate action” would have been taken had I not called.  What, would they have sent more letters? A knock on the door in the middle of the night, complete with dogs, ready to me maul me if I didn’t cooperate with the interrogation? Further harassment and delay of payment while they look additional for ways to avoid payment?

Say what you will about health care reform, but God I wish we had health insurance company reform!!!  So, right now, I’m saving up my money in anticipation of my insurance rates (yes, I’m self insured) going up again.

In the November 2 edition of BusinessWeek, a plan by United Healthcare to reduce the cost of diabetes is explored and lauded as a way to lower health care costs.  Here are the nuts and bolts of the plan that will only be offered to large payors as a way to reduce the cost of taking care of diabetic patients:

• The plan requires patients to follow treatment plans and agree to be tracked by United to make sure the are compliant.  They must agree to see their doctor two times per year.  (Interestingly, every three months is what is common practice.)
• In return, the patient will have discounts on medications for diabetes (co-pays would be waived) and deductibles may be lowered.
• If patients fall off the wagon, and are non compliant, they will be moved back in to their company’s standard plan.
• United will be tracking these patients in a secure database, and may roll out similar programs if the diabetes plan demonstrates improved outcomes and lower costs.  BusinessWeek  cites a statistic that it costs $30,000 to treat a diabetic patient who “suffers complications.”  (No word on what those complications are.)

Aetna insurance has a similar plan which provides prescription discounts to patients with diabetes, hypercholesterolemia, and asthma, among others.  Aetna notes that people are filling more prescriptions, but it is too early to measure improvement in outcomes and reduced expenses.

Sad as it is, I think that this is the only way American health care consumers will finally start taking care of themselves.  Clearly, rants by physicians to patients to take better care of themselves are useless!   It appears as if the only way we change our health habits is by taking  a hit in the pocket book.  So, as hard as it is for me to actually agree with health insurance companies, I think United and Aetna are on to something.  I’ll keep you posted.

As a small business owner, I buy my own health insurance. Two and a half years ago, my husband went to work at a small cutting edge company that offered only one health insurance option.  It wasn’t a good option for us, so I made the fateful decision that we would pay for our own insurance, believing fervently that the freedom provided by the insurance we would buy would be worth it.

In reality, it was something out of the movie Sicko.

My husband had a screening colonoscopy and removal of two benign polyps.  He was deemed “uninsurable” by several insurance companies I contacted.  (Now, mind you, this is not a obese, tobacco spewing, french fry chewing middle aged man!  This is someone that plays hockey every Sunday with former NHL players, bashes down black diamond ski slopes and jumps out airplanes for fun!)

My daughter was diagnosed with reactive airway disease at age 3, and had 2 ED visits at that age.   Nothing since, and she is now 12 years old.  She was deemed uninsurable because she was on flovent and singulair.  At one time I remember saying to the faceless entity on the other end of the phone, “it’s not like she’s on a vent for God’s sake!  She’s a gymnast.”

Click. Dial tone.

So we ended up buying one insurance policy for my husband, and a second for my daughter and me.  Our combined deductible is $7500/year and we pay approximately $500/month in premiums.  According to NPR, since my husbands lay off, we are under insured as we now pay over 10% of our income to health insurance.

Yesterday we got a notice saying that my husband’s insurance would go up $200/year.  This is the second such notice we have gotten in two years.

So, yes, I support insurance reform.  I pay heartily for the coverage I have, and I have no other options.  I am not saying that all we should have is a single payor system, but I think there should be more options then what is out there.  Health insurance for 3 healthy people is the largest percentage of our budget.  Something needs to change!

According to MSNBC, one in four Americans are not going to the doctor due to cost.  To see what resources are out there, I poked around the Internet this morning and came across a great site that provides relief for patients for thier drug co-pays.  Basically, the Patient Advocate Foundation will provide direct financial support to qualified patients to meet drug co-pays for certain conditions.  The conditions include diabetes, inflammatory bowel diseases, psoriatic arthritis, many cancers, rheumatoid arthritis, osteoporosis and hepatitis C.  Providers may enroll patients electronically and there is a number for patients to call as well.  As a test I went through the application process as a provider, and was told that all resources had been fully advocated for the month for the disease I chose.  However, given it is March 27, late in the month, this is understandable.

The site is part of the Patient Advocate Foundation, which offers patients free help navigating through insurance and coding red tape, FMLA, “debt crises” and access to medical and surgical procedures.

Other websites to check out: needymeds–which offers coupons and links to pharmaceutical companies that provide free drugs.  I checked to see if singulair was available, and found a way to get a 30 day supply.  (No, I didn’t order it.)  The Chronic Disease Fund also offers help with medication co-pays for “underinsured” and has an online application process.  The HealthWell Foundation will provide assistance to patients at 400% above the poverty level with medication and provider co-pays.

So why did I post this?  Because all over America patients are not going to see their doctors and are not taking their medications because they can’t afford the co-pays.  The sites listed here generally apply to those with no insurance or those that are “underinsured”, but both physician and patients will benefit from help with these co-pays.  Let me know if you know of other sites and I will gladly post them.

PS: I’m having difficulty getting links to highlight.  I will work on this, and appologize for any inconvenience.

Welcome to PookieMD’s stripped down office, where you get only the essentials.  Patients pay a fee (oh, make it $40/year to belong and get stripped down care.)  Patients get a special card to use to get in the door of the office.  Take an imaginary tour with me…

My office is in an industrial complex, because the rent is cheap.  You open the door into the reception area, and two things are notable: there is no receptionist, and there are no chairs.

There are no magazines (cheaper not to have ‘em, and besides you won’t be waiting long.)  A sign on the wall instructs you to go to the black and white copier and photocopy your insurance information and drivers license.  You then fill out your HIPAA forms.  Next, you fill out a detailed sheet that asks you to verify your allergies, list your medicines and doses, and check off symptoms from a list and describe why you are visiting.  If you do not have/know your medicines, you are invited to call your pharmacy for a list.  If you don’t know your medicines, you can’t be seen by the doctor.

Next, you check off how long your visit with the doctor will take.  You also check off which tests you would like ordered.  You go to a wall kiosk that lists the cost of your visit, based on length of time that you want to  spend with the doctor.  You use the kiosk to get a bill, based on the tests you requested and length of time you spend with the doctor.  At the kiosk, you put in your credit card, and the total bill is charged to your credit card.  If you go over your alotted time, that amount will be automatically added to your credit card, and additional testing will be automatically added as well.  Refunds will also be applied if you use  less time with the doctor.

Once you have paid, you go to the vital sign station, hook your self to the pulse ox/blood pressure machine and write your vitals on your chart.  You insert the thermometer in your ear and do the same.  When you have completed this you go to the rest room, urinate in a dixie cup after you have written your name on it, insert the dip stick  and place the dipstick on a paper towel with your sample.  (If you wanted a urine test.)

You ring a bell to let the doctor know you are ready, and an automatic timer starts.  You visit your doctor, and at the end your time is measured against what you requested, and adjustments are made to your credit card.  You are welcome to turn your bill in to your insurance and fight with them to get reimbursement if you so desire.

It could work.  It would let the patient select what tests they want or don’t want, and let them have as much time as they want with the doctor.  It would put the burden of fighting with insurance companies on the patient   We, as physicians would advise patients, but hey, they are ultimately in charge.  In addition, patients would have a lot of personal responsibility in managing their own health, once they realize how much it really costs.

This type of medicine would have a new title– forget primary care, the medical home, concierge care, etc.  Nope, this would be CostcoCare.

The implications of the stimulus package (The American Recovery and Reinvestment Tax Act of 2009) on small businesses, including medical practices, are greater than what meets the eye.  The package includes a provision that “involuntarily terminated employees” may be eligible for new COBRA benefits under the stimulus plan.  The plan provides a way for terminated employees to continue their previous health insurance at 35% of the COBRA rate, rather than 100% as it was before.  To put it simply, eligible terminated employees will pay 35% of the cost of continuing health care insurance, and the former employer will pay the other 65%.  The employer will then be reimbursed via a tax credit on payroll taxes and federal income taxes with held from employee’s compensation.

Whaaaat?  Basically, the former employer will pay for 65% of the terminated employee’s health insurance, and get the money back by not having to pay as much in payroll taxes.  Sounds great on the surface, but there are some pitfalls.  Chiefly, for small businesses of 2-5 employees, the payroll taxes may not be as big as the payment for the terminated employee’s COBRA insurance.  This would especially apply to low wage employees, whose pay roll taxes will be on the low side.(Picture a solo doc, and two MAs.  One medical assistant is laid off.  Is there enough in payroll taxes to cover the employer’s portion of COBRA?)

Additionally, employers that do NOT charge the full premium will not be eligible for the credit.  But wait, there’s more!  The former employee must pay their 35% before the employer can request reimbursement for the 65% they have paid.  Scarier still, employers may have to reimburse terminated employees if they have previously paid 100% of their COBRA premiums.  The law went in to effect March 1, 2009, but you have until April 15 to get all your ducks in a row.

You, my plucky practice owner, will need to figure out HOW your practice will do this. You must

• Find all involuntarily terminated employees, from on or after September 1, 2008, and make them aware that they may elect COBRA with the subsidy,
• Give these individuals 60 days to elect coverage, and supply them with the forms to do so,
• Create a procedure for refunding the subsidy,
• Figure out HOW you will pay for the employer’s portion of the subsidy.  (Show me the money!)

All this must be done by April15, 2009.

Now, I’m in favor of health care for all (duh), but driving small businesses out of business appears to be a bass-ackwards way to do it.  I’m especially against it when it effects solo docs and small primary care practices that are struggling to make ends meet.

Moral: be careful what benefits you offer, and be careful when you lay off an employee.  It may just drive you out of business.

For more info: read the excellent article “The Economic Stimulus Package and COBRA“.

I may appear to be somewhat of a troglodyte, but I actually have  committed myself to learning to love technology.  I am the proud owner of a smart phone, have mastered my email, and actually use two different EMRs.  So, you see, this qualified me as an expert on EMRs and e-prescribing (wipe that smirk off your face!)

It was with interest that I read “Effect of Electronic Prescribing With Formulary decision Support On Medication Use and Cost” in the December 8/22 2008 issu3e of Archives Of Internal Medicineby Michael Fischer, MD, MS et al.  The authors describe a study in which physicians using e-prescribing with formulary decision support were compared with physicians using traditional paper prescriptions with respect to prescribing tier 1 medications.  When prescribing electronically, the physicians were more likely to choose the lower cost generic tier 1 medication.  There was a 3.3% increase in tier 1 prescribing, with a decrease in tier 2 and 3 prescriptions.  Fischer et al estimate that this would result in an $845,000 savings per 100,000 patients, based on the assumption that each patient filled one prescription per month.

I love saving money, but what was the cost of saving money?  According to the authors, “government estimates of approximate first year costs were $3000 per prescriber.”  In the study, Blue Cross Blue Shield supplied the software to the physicians, along with a free wireless device, access to a secure Web portal, licensing and wireless carrier.  So, the cost was not borne by the participating physicians.

I think as a first step toward an EMR, e-prescribing makes sense.  I do not think that every insurance company should provide physicians with it’s wireless device.  Can you imagine, five different devices for five different insurance companies?!

So what is to be done?  The federal government must mandate one SINGLE e-prescription system that we all should use, and insurance companies should bear the cost, based on percentage of patients enrolled in each plan.  Why should health insurance plans pay?  Because they are the ones that will enjoy the savings!  I think this would be an effective way to usher in the beginnings of an EMR.  Mr. Obama and Mr. Daschle, are you listening?

As physicians, we must look for ways that we can use e-prescribing efficiently and effectively.  We must commit to learning all the bells and whistles, and using it to our advantage.  So, stop hiding behind your prescription pad, and make way for what is inevitable.  Get out there and lobby for what should be done, rather than whining when we get handed the bill for something that will most benefit the health insurance industry!

America’s Health Insurance Plans (AHIP) has released a plan on how to reduce health care costs.  The platform is summarized below:

The new reform proposal would:

Ensure universal coverage by guaranteeing coverage for pre-existing conditions, fixing the health care safety net, giving tax credits to working families and enacting an individual coverage requirement;
Call on the nation to set a goal of reducing the growth in health care costs by 30 percent;
Enhance portability for people changing or in between jobs;
Provide more affordable health care options for small businesses; and
Increase value and improve quality.

An admirable statement indeed. But once again, one must look a little deeper. 

Reducing costs: AHIP points out “Respected studies have shown that patients do not consistently receive high-quality health care and receive care based on best practices only 55 percent of the time.”  Hmm, does  mean that we as physicians are giving ‘low qulaity’ care the other 45% of the time? Who is determining what is ‘high quality’ care?  They advocate using “evidence based standards.”  Aren’t we already doing this?  Furthermore, evidence based standards typically apply to ONE disease state, not the multiple chronic problems primary care physicians deal with.  C’mon give us something fresh!  Stop blaming the doctors for the problem.

AHIP also advocates “exploring” replacing medical liability with dispute resolution. No argument here!  Now who will reign in the powerful legal special interest groups that so effectively court congress?

The reform proposal also advocate controlling fraud.  Now really, how big of a problem is this?

AHIP also advocates pay for performance.  This is a little scary, given the current P4P mess.  I could see this as just another way to with hold payment to providers.  Based on my work as a hospitalist, I find it laughable when the 80 year old post op knee patient is expected to be discharged on day 3.  However, insurance companies don’t care to notice the hypoxia, anemia and confusion attendant with operating on the elderly. Instead, they leave a bright orange sticker on the chart demanding that I justify why the patient is still in the hospital.  Good thing I’m not currently paid for my performance in getting the total knee replacement patient out on time.  The heck with hypoxia!  Clearly I must be doing something wrong and my pay should reflect this!

They also advocate “streamlining” administrative costs.  Gosh, I’d love to streamline my claims, and not have to have extra office staff there to beg insurance companies to pay the bills, or jump through hoops for pre-authorization.  Insurance companies should begin immediately to streamline their administrative costs–they don’t need a government mandate or huge reform to do this–but, I suspect, this may take money from their own pockets.

AHIP states another priority: “Refocusing our health care system on keeping people healthy, intervening early, and providing coordinated care for chronic conditions.”  This is something the health insurance companies should be doing already!  It should not take a “crises” in health care for health care plans to make STAYING healthy a mandate.  They also advocate strongly for “patient centered homes”, a concept that I think is just repackaging of the current model, albeit more top heavy with “midlevel”  and ancillary providers.  

Information technology is embraced (how fashionable!) but no attempt is made as to explain WHO will pay for technology.  Why don’t we admit that the emperor has no clothes?!  There is no money to pay for an EMR and nationalized technology.  Putting it on the backs of primary care practices will drive more physicians out of primary care.  Perhaps insurance companies should pony up for this cost?

They also advocate that everyone should have insurance, regardless of condition.  AHIP also states there should be tax benefits to small businesses so they can offer health insurance, and “large markets should be strengthened.”  They even suggest that the government offer assistance to small businesses. They also advocate broadening SCHIP and medicaid eligibility, as well as offering tax credits to lower income families.    This completely ignores the fact that medicaid reimburses so poorly  that  physicians can’t afford to see medicaid patients!  AHIP also wants  ”community health centers” to receive “adequate” support.  Ah yes, another bail out in the making!

American Health Insurance Plans close with a mandate that the feds should provide a “framework” for reform, and that state governments should follow suit.  They also pledge to “cooperate” with the effort.  After reading the entire proprosal, I am left with just one question: what are the health insurance companies going to do?  Are they going to fly to Washington in their private jets to ask the government to pay for the uninsured?

 Visit the complete reform platform at:

http://www.americanhealthsolution.org/assets/Uploads/healthcarereformproposal.pdf

I am on a reading frenzy, and finally got to the October 17, 2008 issue of Medical Economics.  There was an excellent article by Elizabeth A. Pector, MD, on fixing health care.  I will highlight some key points, but encourage all of you to see the entire article (pages 29-33.)  (www.memag.com)

“Establish equal rights for doctors.”  Dr. Pector advocates appropriate reimbursement, taming the paper tiger, and reigning in “etitlementiasisis” by patients.  Bravo!

“Improve access to doctors.”  She again targets physician reimbursement, but my only question is “how”?  Increasing physician reimbursement will be a tough sell in today’s economic times.  Sadly, I don’t see a way off the office visit treadmill that is the bane of primary care existence.

“Stop the blame game.”  Our society has turned into expert finger pointers.  Bad things just happen.  People die.  Sometimes, physicians make mistakes.  We need to have mutual respect between patients and physicians, rather than mutual antagonism.  And hey, tort reform wouldn’t be so bad either!

“Establish workable technology standards.”  Amen.  “We need to establish workable standards for PHR and EHR systems, including mutually compatible communications platforms.  Also, cash strapped doctors need help to fund changes…”  Technology is here to stay, but we need a coherent direction for all of health care, such that physicians and patients can access records through out the spectrum of medical institutions (clinics, offices, hospitals, nursing homes, etc.) 

“Stop punishing doctors and hospitals.”  See my previous rant on the medicare never ever no pay list.  The no pay list will continue to grow as Medicare pokes its fingers into patient management.  The no pay rules range from common sense to absurd, but there seems to be no one reigning in the free wheeling CMS.

“Take responsibility.”  Americans need to pony up and take responsibility for their choices, rather than shifting the responsibility elsewhere.  This will take giant social change, from throwing out the television and X-box to eating meals that don’t come in a “super size.”  Are we up for the challenge?

“Refocus the health insurance industry.”  Pector notes that physicians should be paid for what they do, with out the “gamesmanship” so common today when dealing with health insurance companies.  Additionally, she notes that insurance companies could actually (don’t faint!) assist in helping patients follow through on life style changes and medical compliance.

I think Dr. Pector is my twin sister of a different mother! Keep fighting the good fight, Dr. Pector!

Final Installment on As the Medical Home Turns:

Yes, students, today is the last installment in PookieMD’s dissertion on the ‘Medical Home’.  At our last session, we were midway through reviewing the “10 Simple Rules for the 21st Century Health Care System,” rules to guide the redesign of the health care system.  These guidelines were put out by the National Committee for Quality Assurance.  Why are we torturing ourselves with this tedium?  Because this may the  measuring stick by which CMS (Center for Medicare and Medicaid Services) will use to reimburse our practices.  And that means, of course, insurance companies will follow suit.  Following are rules 7-10 with my pithy commentary:

“7. The need for transparency. The health care system should make information available to patients and their families that allows them to make informed decisions when selecting a health plan, hospital, or clinical practice, or choosing among alternative treatments. This should include information describing the system’s performance on safety, evidence-based practice and patient satisfaction.
8. Anticipation of needs. The health system should anticipate patient needs, rather than simply reacting to events.
9. Continuous decrease in waste. The health system should not waste resources or patient time.
10. Cooperation among clinicians. Clinicians and institutions should actively collaborate and communicate to ensure an appropriate exchange of information and coordination of care.”

Item 7: “The need for transparency.” To me this sounds very similar to ‘rule 4′, free flow of information.  The salient feature is that the health care ‘system’ should make information available to patients about health plans, hospitals…etc.  Who will be responsible for each aspect–are physicians to review a patent’s health plan with them, and review each hospital the patient may go to?  This is an incredibly broad assertion of what needs to happen, but with no clear plan of who exactly needs to provide this information.  Part two, which references the “system’s performance”, appears to be directly related to measuring safety (think the never/ever no pay rules, for example), and also appears that your practice will be measured on evidence based practices and patient satisfaction.  We already discussed evidence based practices, which I consider the basis of modern Western medicine. However, the patient satisfaction issue is murkier.  What exactly IS patient satisfaction?  Would I get higher scores if I didn’t collect copays, gave out lots of oxycontin and ordered any test the patient saw on TV?  Clear criteria need to be established,  e.g. are patients seen with in 15 minutes of their appointment?  Are appointments accessible on a daily basis?  I’m not buying the criteria of “Rate PookieMD on a scale of 1 to 10–where one is the worst physician you ever saw, and 10, PookieMD is better than Marcus Welby, House and Hawkeye Pierce combined.”

Item 8: “Anticipation of needs.”  Yes, indeedy, I certainly try to anticipate my patient’s needs.  More importantly I try to anticipate outcomes.  If I do x, y will happen. But, I also try to have a plan in case z happens.  I can’t anticipate a patient’s every need, but I can use the best of my knowledge and resources to try to move the patient toward health.  Anticipation of needs smacks of wand waving, rather than reality.  Anticipation of outcomes is medical science, and an attainable goal. 

Item 9: “Continuous decrease in waste.”  Sounds good to me.  I hope that includes not wasting MY time filling out endless forms and jumping through hoops to make the ‘Medical Home’ a reality.  It is interesting that the Rules state the health care system should not waste resources or patient time, but makes no mention of physician time.  I’m all for decreasing waste, and hope that much more in depth thought goes into developing the operations and processes of the ‘Medical Home’, so it is not a gigantic bureaucratic wasteland.

Item 10: “ Cooperation among clinicians.”  Please do not patronize me.  Cooperation is a kindergarden skill, and doesn’t belong on this is on the list.  The physicians I know and work with are dedicated and caring, and certainly cooperative.  We don’t always agree on management, which is HEALTHY, and we certainly can be snappy when fatigued, but I think this is rule is over kill.  Shall we form a circle and sing Cum By Yah?

So my final take on the “Medical Home” is that it is a bunch of ’rules’ that primary care  practices are trying to do already.  (Or as close as they can get with the limited resources they have.)  What it woefully neglects is how systems should be put in place to make health care, health information technology, and a much needed emphasis on PATIENT CENTERED care a reality.

Back to the drawing board.  This time, make sure you invite the physicians in the trenches that actually do the work–the family practice physicians,  the internists and the pediatricians, to guide the guidelines.