Big business and doctor visits

[williamranks]

http://www.azfamily.com/story/29184292/ ... cker-shock

[AJMD429]

It started when patients allowed their insurance company to make choices for them...then doctors saw an opportunity to charge high 'unseen' (by the patient) prices for procedures, and used the 'visit' as a loss-leader. Then the insurers ratcheted down the procedural reimbursement and the only thing left was the loss-leaders. Then when the physicians wanted to raise prices for office visits to cover their basic overhead, patients cried and whined because they were used to the doctor spending $4.00/minute on overhead, but offering a 30 minute visit for $50, and doing all the after-hours documentation and test reviewing for 'free', and when the docs lost their cash-cows, that 30 minute visit became a 25 minute visit and still needed to cost $110.00 for the doc to hope for a $20/hour income. Then the docs fought back by making a science of finding what things were well-reimbursed and doing more (even if not needed) and what wasn't well-reimbursed, and finding excuses NOT to do those things (even if needed by the patient). Then insurance fought back by nit-picking things like how many adjectives were used (seriously - I've even seen where they disallowed the counting of the word "severe" as a descriptor of 'severity'), so the docs got EMR that wordsmiths the simplest visit into a huge tome.

Meanwhile the patient is caught in the middle.

Unfortunately, once the hospital buys a physician, the physician loses control of everything about how he or she treats patients, but when you can go from working 70 hour weeks for $70,000 to being 'guaranteed' a 50-hour work week and making $140,000 a year, you look at it like twenty hours a week you're given with your family, plus a doubling of your pay. Hard to turn down, when some of these docs start out at age 35 with a $100 car, a ghetto apartment, and $350,000 in debt.

A BIG part of the problem is that the politicians have made almost every manner of 'getting around the inefficiency and unfairness' illegal - so we who are trying to do things the right way and honestly are getting caught in situations where we have to either provide shoddy medical care (which we feel is unethical and contrary to our Oath), or join the rip-off crowd just in order to survive.

[2571]

Thank God for the ACA.

[Larkbill]

AJMD- We're seeing a ton of docs in our area moving in to both pure concierge care and some sort of hybrid where they take any insurance but waive deductible and co-pays with a yearly concierge charge.

What are your feelings about this type of practice? How long before the drones in DC try to squash it?

[jeepnik]

Before Obama care kicked in I was warned by my sis (worked for Anthem at the time) that things were going to change, and not for the better. She actually recommended going with Kaiser at least until things worked themselves out. Turned out to be a good move.

Granted it's a big organization, but I actually have more personalized care from my primary care physician and his team. And, team is the operative word. I may not always talk to the Dr. directly on some matters, but I can get appointments in the fairly near future and their urgent and after hours care is pretty darned good.

Kaiser, like all health care institutions is facing issues with all the changes, but so far they haven't sacrificed patient care that I can see.

[AJMD429]

AJMD- We're seeing a ton of docs in our area moving in to both pure concierge care and some sort of hybrid where they take any insurance but waive deductible and co-pays with a yearly concierge charge.

What are your feelings about this type of practice? How long before the drones in DC try to squash it?

The hardest part is that the regulators already try to stifle everything we do that either improves the quality of care or decreases the cost. As a fo- instance, before insurance was involved in office based practice, we had three levels of charges, just like an account or an attorney might have, which enabled us to do things after hours at a lower rate when we weren't having to pay employees to be there, or to do things over the phone for about half the price that we had to charge for an office visit. When medicare decided to require "face-to-face contact" for every billable service, patients and families had to take time off work to come to the office, pay a co-pay, plus then to provide the service is much more costly for us and therefore also to the patient, and ironically, to the insurance company who assumed it would save money to disallow billing for telephone services. Recently, they (decisions of even private carriers hinge on what the government/Medicare dictates) have decided to allow some limited telephone-provided-service charging, but the rules are so intricate, compliance is so difficult, reimbursement so ridiculously low, and the penalties so severe, that most of us are afraid to try billing for telephone services, so we still make them come in. If the patient gets worse and comes in within a couple weeks for a visit 'potentially related to the telephone call' and you forget to un-bill for that $15.00 phone call, you can face hundreds of thousands of dollars in fines or even jail time. Anthem is the worst of all when it comes to enforcing 'rules' - they denied visits I billed for because "it is not permitted to have a student do the documentation", even though I hand-write ALL my documentation, and can prove it. When a government-subsidized corporation is able to LIE and assert the consequences with penalties of fines and jail-time, you can't fight back.

The nice thing about the concierge type services is that so many different types of service and fee schedules are coming along that patients will likely find one that provides the type of care they want at a price they can afford.

We calculate that we can provide the average patient complete office-based care (a complete annual physical plus two or three follow up visits) for around a dollar a day or so. That is less than most people spend on fast food or cable service or any other number of things they say are not as 'important' as healthcare. Of course people insist healthcare is incredibly important, but then turn around and gripe if it costs more than they spend on coffee or cigarettes...

Of course, adding to the problem, is that the government has essentially prohibited affordable insurance coverage that only covers unpredictable major medical events (which is the whole purpose of 'insurance'), so we wind up paying inflated prices for every little inefficient thing that the insurance requires the doctor to do (you don't get the $1.50 charge for a regular dipstick urine test that costs the doctor $1.25 to do, because it is unreliably reimbursed at maybe $0.95 on average, so the doctor justifies the $28 charge for a test costing him $8.00 to do, and gets paid $12.00 - CLASSIC money-wasting 'cost-containment' policy.... ).

Most people have NO idea what they pay for health insurance anyway, because I see people every day who are so uninformed that they actually complain because their insurance costs them three or four hundred dollars a month. That is just a number they see on their pay stub which represents additional money to that already removed from their employer's allotment for their position. Nobody over 35 years of age is going to get coverage as an individual for less than about $1,200 a month, or as a family for less than about $1,800, regardless of whether some or all of the money comes 'from their employer', which simply means it is money allocated for that position that could have been income for the patient. When all this money is taken away from a person without their knowledge, or consent, it leads to the socialized medicine we have today, with all of the excessive costs and inefficiency. It also leads to an 'entitlement' mentality, where it is assumed all 'health care' should be 'free' somehow.

Keep in mind, that 50 years ago, very few people had a health problem severe enough to bankrupt them but not kill them. Cancer always killed, heart attacks and strokes and major trauma we're also unlikely to result in a situation where spending half of a lifetime earnings would do anything other than result in a lavish funeral. Now, probably three-fourths of us will have such an event, where half a million dollars spent on chemotherapy or bypass surgery or intensive care will result in our living longer. Then many of us will have a second (or third) 'event' which we will likewise expect to be treated as if there is some unlimited pile of money to pay those who provide the care.

There isn't such a pile - all the funds are either extracted (visibly or invisibly) from your paycheck, either as 'participation fees' or taxes or just hidden premiums.

Most of us feel rightfully entitled to such services, just like we would feel entitled to a new house if a tornado flattened our house and we had paid our insurance premiums. The difference is that you can have 50,000 people pay 1/50,000th of the cost of a house every year in premiums because less than one on 50,000 will get hit by a tornado in a given year. When a majority of us are going to have such a catastrophe (as with 'health') that it costs 25% to 50% of our entire lifetime earnings, the only choice is to pay extremely high insurance premiums, or be willing to accept disability or death when tragedy strikes. Any other solution offered by policymakers is simply mathematically impossible. Most of us will work about 50 years, so if we 'expect' a $500,000 'benefit' we'd better be prepared to pay at least $10,000 per year in premiums, and that is if we expect the insurance administration to be done as charity without profit, and if we don't expect things like physicals, mammograms, blood pressure medication, and so on to be covered - just the catastrophic stuff.

There could be some small incremental savings on the cost side of things, if we were willing as a society to accept less than perfect outcomes, AND if the government would quit interfering with competition by regulating everything. As we see everywhere, government intervention usually has the opposite of the stated impact, and this is particularly evident when they claim to want to 'reduce the cost of healthcare'. Every single policy they implement has the opposite impact, yet both Republicans and Democrats continue to ask the government to "do something" about the high cost of health care... The ONLY thing government could do that would help would be to do NOTHING, and to un-do all the stupid stuff they've done over the past 100 years to 'improve quality' and 'control costs'.

Finally, the other issue is that it is completely unrealistic to expect insurance companies to care about long term cost-savings, much less long-term health per se.
Why? . . . It is because the public (particularly labor unions) was so stupid and shortsighted and selfish that they allowed insurance companies to sell insurance to employers, instead of directly to individuals. There was a brief 'smoke and mirrors' cost reduction (typical of the maneuvers that satisfy 'liberal' and 'conservative' constituents alike) that has long since disappeared, because the primary motive for that was to conceal the true cost of premiums. The end result is that the average person changes health insurance companies every few years (either because of job change or employers contracting with different insurers), so those insurance companies have NO incentive to reduce costs beyond the immediate 10 or 20 month period. Given that most people don't have very many potentially lethal conditions developing before age 45 or 50, and Medicare is where they will be dumped within 15 to 20 years, even if they are lucky enough to have the same health insurance during that decade or so, it makes more financial sense to provide minimal and inexpensive care then, regardless of the consequences when the patient is in his or her sixties. Then, by the time they are in Medicare, the amount of monthly premium they are putting in is so ridiculously low versus what they expect to be entitled to if they have a heart attack, stroke, cancer, or major injury, that Medicare really prefers them to die before they start "consuming resources". Think about it, if you were running a business where your customers were likely to expect half a million dollars in services during the next 10 or 20 years, with you accept them as a customer if they merely paid a couple thousand dollars a month to you...? Remember, the money already taken during the years that you were employed, allegedly for the purpose of 'providing healthcare after retirement', has already been squandered by the politicians of your favorite political party (yes, they both are guilty - another smoke-and-mirrors event is the weighty decision between the lesser-of-two-evils we engage in every few years ).

I know it sucks, and it is unfair, and there's plenty of blame to pass around against patients, physicians, employees, employers, insurance companies, unions, etc., but none of this would be a problem if we had not exchanged God for government. The Demoncraps did it long ago, because they worship material things and money, and think handing money to others in exchange for power is somehow socially constructive, and the Republicrits did it because too many of them didn't have enough true faith in their God, so they decided to hand over His authority to 'government' and thus we have the 'War on Drugs' and all sorts of other authoritative nonsense that destroys individuals.

We expect near-immortality, which is a bargain with the devil, and we didn't even have the integrity to bargain with our own money; instead we used money stolen from our friends and neighbors - and children and grandchildren by a government we have given illegitimate powers.

We are only getting what we deserve, collectively. Unfortunately the actions of the 'majority' have condemned those who still believe in freedom, God, and fairness, to go down the tube with all the mindless, wealth-envying, materialistic 'progressives' who have destroyed health care. The fact that they blame 'big corporations' for it all doesn't un-do the fact that whenever you give government control over the economy, the 'greed' of capitalism morphs from providing the best services to the most people for the least cost, to providing services to the self-anointed wealthy elite, and passing the costs on to the working-class - - - the exact opposite of what they profess to be their goals.

Whether the discrepancy is due to evil intent or naïve idealism, I don't know - but the result was predictable from the beginning.

[Gaucho Gringo]

It is all about big medical and pharmaceutical corporations making big money at the expense of everyone's health unless you are in the top 5% that owns them anyway and then you don't have worry.

[Ray]

Deleted.

[AJMD429]

It is all about big medical and pharmaceutical corporations making big money at the expense of everyone's health unless you are in the top 5% that owns them anyway and then you don't have worry.

More like the top 0.5%, and don't forget the insurance companies.

If we'd stuck with true free market capitalism those big corporations would have to compete and provide either quality or lower prices like most other industries - but instead we opted for socialism with health care (the left prefers the synonym of 'crony capitalism' because it disguises the true damage of socialism and appears to blame 'capitalism').

I pray we can get the free market capitalist system back; it would do far more good for society, especially for the working class, than just making quality health care affordable.

[Old Ironsights]

It is all about big medical and pharmaceutical corporations making big money at the expense of everyone's health unless you are in the top 5% that owns them anyway and then you don't have worry.

There is also, of course, the simple fact that 909%+ of all Pharma R&D goes NOWHERE (drugs that fail to work) and all that expense has to be recuperated somehow... PLUS the FDA "regulatory costs" of bringing the 1% of effective pharma to market drives the costs up further.

Is it any wonder why companies like Bayer (Germany) and Teva (Israel) etc. are producing most of the "new" pharma these days?

In Pharma, what you CAN patent MUST be expensive because it is the only thing that pays for all the stuff that was not patentable...

[Old Ironsights]

Thank God for the ACA.

Thank Obozo, the Black Robe Mafia and the RINOcrats.

God had less than nothing to do with it... God does not take, at gunpoint, from one to give to another.

That is the provence of another altogether.

[new pig hunter]

yesterday in the L.A Times .....
http://www.latimes.com/business/la-fi-l ... olumn.html

Cheers,

Carl

[Ji in Hawaii]

Say what you will about Obama-Care, before Obama-Care NO insurance company would take me because of my preexisting back issues even though those issues are fully covered by Workman's Comp. I have a Kaiser plan now which is half the price of the HMSA/Blue Shield plans offered here in Hawaii. I've had to go to the ER 3 times within the last year. Without Obama-Care I might not be typing this post right now, or in debt up the yin-yang to a hospital that I can't afford. It certainly don't mean I like Obama, far from it but I am happy I finally got medical coverage after several scary years without it.

[Larkbill]

AJMD: Thanks for than incredible and informative reply. Wish I lived close enough to have you as my doc.

[Grizz]

Doc, you hit that one out of the park.

we live in interesting times . . .