Gentle Thoughts for Today 5/15/12

Gentle Thoughts for Today 5/15/12

Birds of a feather flock together...and then shit on your car.

A penny saved is a government oversight.

The older you get, the tougher it is to lose weight, because by then
your body and your fat have gotten to be really good friends.

The easiest way to find something lost around the house is to buy a
replacement.

He who hesitates is probably right.

Did you ever notice: The Roman numerals for forty (40) are XL?

If you can smile when things go wrong, you have someone in mind to
blame.

The sole purpose of a child's middle name is so he can tell when he's
really in trouble.

What Do Doctors Really Do?

It depends on who you are as to what you think doctors do.  This was posted on a doctor’s web site that I visit regularly.  I particularly like “What my friends think I do” and “What I really do”.  Only my desk is much messier than that. 

I Couldn’t Say it Better: Medicare vs. Doctors

Http://Insureblog.Blogspot.Com/2012/01/Medicare-Vs-Doctors.Html    

Tuesday, January 17, 2012

Medicare vs. Doctors

Suppose you were self employed and the government decided not only which services they would pay you for, but how much you could accept and not a penny more as full payment for services rendered. How would you like that?

Believe it or not, that is exactly how Medicare treats doctors.

They provide them with a list of roughly 7500 different services that are reimbursable and then hand them a price list as well.

The doctor does not get to decide which services are best for the patient, nor are they allowed to set a price for their time. If a doctor CHOOSES to provide additional services not on the list because it would be of benefit to the patient they do so at their own expense.

Is there any chance that Medicare can get all those prices right? Not likely.

What happens when Medicare gets them wrong? One result: doctors will face perverse incentives to provide care that is costlier and less appropriate than the care they should be providing. Another result: the skill set of our nation’s doctors will become misallocated, as medical students and practicing doctors respond to the fact that Medicare is overpaying for some skills and underpaying for others.

The problem in medicine is not merely that all the prices are wrong. A lot of very important things doctors can do for patients are not even on the list of tasks that Medicare pays for. Some readers will remember our Health Alert on Dr. Jeffrey Brennan in Camden, New Jersey. He is saving millions of dollars for Medicare and Medicaid by essentially performing social work services to reduce spending on the most costly patients. Because “social work” is not on Medicare’s list of 7,500 tasks, Brennan gets nothing in return for all the money he is saving the taxpayers.

We have also seen that there are other omissions — including telephone and e-mail consultations and teaching patients how to manage their own care.

Welcome to Medicare. We trust you will enjoy the ride.

In addition, Medicare has strict rules about how tasks can be combined. For example, “special needs” patients typically have five or more comorbidities — a fancy way of saying that a lot of things are going wrong at once. These patients are costing Medicare about $60,000 a year and they consume a large share of Medicare’s entire budget. Ideally, when one of these patients sees a doctor, the doctor will deal with all five problems sequentially. That would economize on the patient’s time and ensure that the treatment regime for each malady is integrated and consistent with all the others.

Under Medicare’s payment system, however, a specialist can only bill Medicare the full fee for treating one of the five conditions during a single visit. If she treats the other four, she can only bill half price for those services. It’s even worse for primary care physicians. They cannot bill anything for treating the additional four conditions.

Who comes up with these rules?

Oh yeah, the government. That explains it.

EMR Rant – 4 – Templates and Other Fixtures

Techno-Dino (that would be me) is still having issues with that ol’ electronic medical record.  It has things in it that make no sense.  At least to me. 

For example – if the page ends and needs a signature near the bottom, it will almost always put the signature on another page.  I print everything out, because I don’t trust this computer record (dinosaur, remember?).  So I waste a whole piece of paper saying I electronically signed the record. 

I have tried to write letters to consultants on the blasted thing.  It is not yet worth it.  Maybe I will figure it out within the decade.  After all, this is only 2011.  I couldn’t change any spacing of paragraphs, lines, etc.  I’ve been word processing since 1975 (give or take a couple of years – yes, I really am that old, folks), and can’t figure out how to get this one to behave. 

I finally just opened up “Word” and wrote the danged letter over.  I have decided to do this from now on.  I may even save a copy of my letterhead as a shortcut on the desktop because I know how to do that.  I really am somewhat computer literate. 

I’m still learning how to make my own “templates” for things like “normal GYN exam” and stuff.  I probably do a lot more typing than I really need to do. 

Plus, for some reason, now the EMR has spell checker.  However, it doesn’t know how to spell any of the medical words – you know medications, procedures, instruments and other stuff I use all the time.  This includes medications and directions it puts in itself.  So I have to teach it to spell things I didn’t put in – it did????

Remember, this is supposed to make your visit simpler???  I know that the government wants to collect data from these notes.  That’s probably all they are good for.  I’m not sure they are even good for that. 

“Uncompensated” Medical Care - Charity

Back in the old days, doctors used to do a certain amount of what they called “charity care”.  They would care for people who were truly poor.  They knew that they were not going to get paid in cash.

Sometimes a church, a school or some other organization would raise money to help pay some of the costs of that care.  People paid what they could.  They paid in chickens or pigs or apple pies.  If you couldn’t pay with money, you might come by and mow the doctor’s lawn or do some other work that needed to be done. 

Martha who kept the doc’s books would kind of figure out when your bill was paid.  Everyone (except possibly the IRS) was happy.

Sometime after WWII, employers started offering “health insurance” instead of increasing employee’s wages.  Doctors didn’t mind, because they got paid what they charged in real money. 

Then Washington decided that the government needed to get into the insurance business.  Medicare and Medicaid were born.  The government decided that it was not going to pay the whole bill.  Instead they would pay what they wanted to pay. 

More and more people qualified for these programs.  As the cost of the programs went up, what the government paid went down.  Doctors at first made up for this by working harder, and by charging other patients more. 

Insurance companies decided they didn’t want to pay the whole bill either.  They started to demand the same discounts as Medicare.  Doctors worked harder.   Patients got less time for each visit.  Our hours got longer.  Your waits got longer. 

Medicare and insurance companies developed more rules and regulations like prior authorizations, formularies, preferred providers and ICD and CPT codes.  Did that sound like a bunch of garbage to you?  Until I started “doctoring” it did to me, too.  They didn’t teach you all that stuff in medical school when I went, either.

Doctors had to hire people just to do the billing and “chase down the payments”.  Then they weren’t payments, they became “reimbursements”.  “Patients” became “Insureds” and office visits and surgeries became “claims” and “procedures”.  Insurance companies started “bundling” all your care.  Surgeons get paid the same no matter how many times they see you in the three months around your surgery.  OB doctors get paid the same for the entire pregnancy and 6 weeks afterwards.  It doesn’t matter how many times they see you in the office or the hospital.  The only thing that increases the fee is a cesarean section.  Some insurance companies won’t pay extra for that. 

There isn’t enough room here to discuss what happened when the lawyers got their fingers in the mixture.  Besides, my doctor wants me to watch my blood pressure.  Let’s just say that a lot more testing goes on these days to keep from being sued.  It costs lots of money and doesn’t add much to the answers we get.  Lots of paperwork ensues. 

Patients – pay attention here – that’s you! – are now so far removed from what things cost that they don’t care about what tests are done.  They want the CT scan or the MRI.  They want all the blood work, all the nuclear medicine testing, and all the consultants.  The insurance is paying for it after all.

Not really.  If you have private insurance, your premium goes up if you keep getting tests.  If you have “public insurance” the taxpayers pay for it.  Either way, it’s busting our system. 

Ask people who don’t have any insurance.  I have lots of them in my practice.  You see, I don’t take insurance any more.  I have gone from 4 employees to 1.  We will give you the papers to submit your insurance, but we won’t fight it for you.  That saves us hours on the phone.  I don’t participate in Medicare and Medicaid.  I don’t have to take those huge discounts.  So I get paid for my time. 

I get to spend more time with my patients.  My overhead is a whole lot less.  So I don’t have to charge for all those people that used to work here.  We have time to help figure out where the least expensive place for an MRI is and help our patients find other doctors to help them.  I also found a lab that gives discounts for cash.  We also decide what tests we really need, not what insurance will pay for. 

This is what I went into medicine for. 

Here’s another blog with another version of this:

http://roadtohellth.com/2011/11/why-does-the-cost-of-healthcare-keep-going-up/

It’s About Time!

Now You Can Monitor Insurance Rate Hikes

Now you can monitor any insurance company’s rate hikes, as well as the reason for doing so.  This article in USA Today explains that there has been a 9% hike in the average price of health insurance this year!  Earnings per share are 46% over estimates!

The web site to check is http://companyprofiles.healthcare.gov/.  The article is:

  http://www.usatoday.com/money/perfi/insurance/story/2011-10-07/health-insurance-rate-hike-website/50682044/1

Confidentiality and Medical Records

HIPAA – Health Insurance Portability and Accountability Act

Are you frustrated because you called the doctor’s office about your Mom’s medications and nobody would talk to you?  Are you angry because you called to check on your husband’s prescription and the pharmacy couldn’t tell you anything?  Did you want to get a copy of your latest lab results, and they said you needed to come sign a form?  These are all things you can thank your federal government for. 

Several years ago, the government decided that there was too much sharing of information in the medical profession.  So they set to work making rules and regulations about it.  As usual, everything got more complicated. 

Now there is that form that you have to sign at every doctor’s office.  You see it at the dentist and the pharmacy, too.  We have to protect your privacy and tell you what your rights are.  The only “entity” who can invade your privacy without asking is – are you ready? – the government!  If they want something, we have to give it to them, without asking YOU.

It used to be that I could just call radiology or the lab and ask for your results.  Not anymore.  Now I need a records release all signed and witnessed.  Can I send your Pap smear results to your medical doctor?  Not without your signed consent.  If I send you to another doctor for surgery, then you come back to see me, I need to get a records release to get the operative record if s/he forgot to send it to me. 

Those sign in sheets everyone used to have?  Those aren’t really legal anymore, either.  You can see who else has an appointment etc.  That’s a VIOLATION!!!!!! (Insert Mr. Impatient giggling here – he thinks that’s funny).  We’re even supposed to keep our screens turned away from patients so you can’t see what we’re typing.  What???

Basically, this law has created more paper work.  It makes most of us in medicine much more paranoid about what we can and can’t say or send.  It also makes us very, very careful about whom we talk to about what.  There are disclaimers everywhere about changing identifying details unless we get permission. 

When the law first started, we even had major discussions about whether or not a fax signature was a “legal” signature, or whether we had to have the “original” signature.  Somehow, as fax machines have become more common, that has worked itself out.  It’s OK to fax your signature now. 

The law was intended to maintain your privacy.  I think, as usual, bureaucracy has made things more complicated without necessarily doing what was intended.  It came from the government.  So is anyone surprised?