Thursday, January 31, 2008

We messed up!

A quote from 1999. And it is 2008, and it only got worse....

Doctor Discontent N Engl J Med 1999

Almost a decade ago, an article in the NEJM about financial incentives in managed care systems led to an outpouring of emotional responses from physicians (Doctor Discontent N Engl J Med 1999 340: 649-653).

It seems like many physicians had noticed the warning signs and the trends that have brought us to a strained and unsustainable system. Why the physician community did very little to address these critical defects is a testament to the incompetence of our leadership and the need for a new way of thinking.

The following are excerpts from the 1999 NEJM correspondence.

"Many of us feel we were sold a bill of goods. As our friends enjoyed life, we studied our way through college and medical school. Years of long hours, low pay, and tremendous responsibility in internships, residencies, and fellowships were accepted as rites of passage. We were taught that the secret to good medical care was to spend time listening to our patients. Instead, we hear the economic hounds baying at the door of the consultation office, asking us to see more patients in an hour than we know we reasonably can. It is so difficult to repay our loans, support our families, and run our offices in the current environment. The explanation is the bottom line."
"Perhaps the ultimate model needs to be one in which patients share some financial responsibility for their own use of health care services so that they begin to value the concept of cost-effective, appropriate care."

"Even as a diagnostic radiologist, I am not shielded from the control of managed care. Daily we fight little scheduling battles, trying to explain to patients why they can come to us for their chest films but not their computed tomographic scans, or why someone failed to obtain authorization for their magnetic resonance imaging (MRI) studies. "

"I am fed up, and even though I am only 49 years old, I have already cut back to half-time. Within two years I will be fully retired. It is just no fun being a doctor anymore. But what really scares me the most is that as I get older, I will become a more and more frequent consumer of health care services delivered by disgruntled physicians who have incentives to give me less and less care."

"We young physicians are forced to learn "billable diagnoses," formularies for different health plans, key diagnoses for which medication costs will be paid, and insurance codes, in order to know whether we can order laboratory tests or studies, instead of ordering the studies and treatments appropriate to the patient's presentation or the known diagnosis. Notes and charts are increasingly organized to aid utilization review rather than to represent clinically useful medical histories."

" Who would have believed a generation ago that the skills of listening and thinking would no longer be considered essential in dealing with people in pain? Who would have believed that these committed physicians would not be followed by like-minded persons? Who would have believed that my [physicians] judgment, honed after years not just of study but of day-to-day dealings with people and their problems, would be constantly questioned by nameless and faceless corporate minions armed with rule books, or that these same anonymous people would determine what continuing education was or was not appropriate? "

We messed up!
Time to do something!

Disgruntled Docs Go Out of Network

A quote from Healthcare NBIC:

Hundreds of pissed off MDs gathered at a seminar in New York recently to find a way to beat the healthcare system, specifically the managed care system that they say underpays, overmanages and cheats both doctors and patients. New York has the highest percentage of doctors per patient in the U.S., 328 per 100,000 versus the national average of 281 per 100,000, and the highest concentration of world class hospitals. It's a good place to be a patient, but apparently a lousy place to run a medical practice.

"Out of Network Practice: Opportunities and Benefits," sponsored by the Business Development Institute and Castle Connolly Medical, Ltd., showcased doctors who operate outside of the managed care system. Their patients pay on the spot and later file with their medical insurance carriers for reimbursement -- usually partial reimbursement. Patients get the doctor they want and therapies that are not subject to the care restrictions cooked up the the managed care beancounters; doctors charge what they need to make a living, do without expensive medical billing staff, give more time per visit to a smaller patient roster, and -- to hear them tell it -- get a better quality of life as the healers they always wanted to be.

Monday, January 28, 2008

I Am A Disgruntled Doctor

After having suffered long enough, a few physicians have decided to clearly state what is wrong with the present healthcare system. They have founded an organization that, in my opinion, represents physicians far better than the AMA, who has lost track of its original mission to represent physicians many years ago.

I welcome the opportunity to introduce you to the American Academy of Disgruntled Doctors.

Here is a quote form their website:

AAdD Principles

Our patients' welfare is always foremost in our minds, and it is for our patients that we shall strive to fix the broken health care system.

1. Health Insurance is not Health Care.

This simple fact clearly needs to be explained to politicians and the media who keep confusing the two. Health insurance is the problem underlying America’s health care woes. It is certainly NOT the solution.

Health Insurance needs to be considered as a method to protect personal finances, not to assure access to health care. Catastrophic health insurance with high deductibles with or without voluntary Health Savings Accounts are a reasonable financial protection. First dollar or low deductible/low copay health insurance plans are a recipe for excessive demand on resources, artificial cost controls, regulatory intrusion, Stalinist 5-year plans, and failure of the medical economy.

In economic terms, demand for health care is NOT inelastic. Price DOES affect demand. When patients pay $15 for $250 worth of health care, the demand for such care increases beyond what is truly needed.

Economic pollution has overwhelmed the medical economy to the point of there being no functional medical economy at all. Economic pollution includes real or effective subsidies, artificial price ceilings, intervening intermediaries, government regulations and other non-free-market forces that prevent the balance of supply and demand. Health insurance companies effectively serve as extra-government tax and subsidize entities. The employer-based first-dollar style health insurance system in America is the reason why health care is expensive.

It is a lie to say that technological advancement is a cause of increased costs of medical care. Technology increases productivity and decreases costs in every other segment of the economy. An example is that computer technology has exponentially advanced in the last few decades while costs for computers have massively declined. Health care costs rise because the free market has been abandoned. Patients don't have a clue what a given medical intervention really costs. Doctors more often than not have no clue what they are being paid for their service. It is time to stop wondering why health care costs soar, and realize that the answer is the loss of the individual involvement in the cost control process. Doctors and patients alike have defaulted to insurance clerks and government agencies to make our medical financial decisions for us. Therefore only the government and insurance clerks currently control costs. What idiot thinks that is smart?

Money is a universal translator for valuation. It is appropriate, acceptable, and indeed necessary to charge money for our expertise. Individual patients and doctors feel ashamed to talk about money. It is time to realize that the true shame comes from not talking about money. Medical care costs money. It really truly does. Stop ignoring the facts and things make more sense.

2. It is the patient's health insurance, not the doctor's.

It is in the best interest of the country for physicians to cease direct interactions with 3rd party insurance payers. The health insurance company works for your patient. You do NOT work for the health insurance company. Indeed, your patient needs to deal with the hassles of their insurance company in order for the insurance company to mend its ways.

Health insurance forms and reimbursement are so difficult because the insurance companies are motivated to make them so, and have no motivation to make them easy for doctors, or to “reimburse” doctors in a timely fashion. If physicians did not get involved with insurance companies at all, the insurers would need to pay heed to their clients complaints and streamline reimbursement to their clients (our patients).

3. Doctors should be paid what they charge, right away.

Remember, “reimbursement” means "paying back". The only way that reimbursement has any meaning is if the insurance companies pay back the patients. This means the patients have to pay the doctor first. Doctors can happily accept credit cards, cash and maybe personal checks. Some of us are happy to be paid in chickens. But we are not happy to have insurance companies pay us.

It is not only acceptable to charge patients directly for services, but indeed it also the responsible thing to do. Remember it IS the patient’s insurance company, not the physician’s. Doctors need have NO direct interaction with a patient’s health insurance company. Physicians need have no coders working for them. No CPT codes, no E&M codes, no ICD9 codes. Just write up an invoice and slide the credit card. There need be no further insurance frustrations in medical offices if we stand up together. “We expect full payment when services are rendered” is a phrase that we should actually mean.

4. It is time to castrate "pre-authorization"

Doctor's can "just say no" to being unpaid consultants to an insurance company's cost control policy. If the 3rd party payer wants to discuss a potential procedure with you, or insist on a cheaper drug, that is fine, but they must pay you for your time.

5. Doctors provide valuable professional consultative services that cost time and money.

For as long as you are contractually stuck with 3rd party-payers, it is fully appropriate to bill your patient for the time spent obtaining pre-authorization. It is also totally appropriate to bill them for calling in prescriptions, answering phone calls and responding to emails. That an insurance company does not pay for these actions in no way lessens their value, nor the value of the time you spend accomplishing them. We need to have a mindset as follows: “I don’t know what your insurance will reimburse to you. But here is the amount that you owe.” Answering phone calls, emails, and calling in prescriptions are obviously all billable services. To be thoroughly clear, we at AAdD don't care whether the insurance companies think they are billable or not. We consider it undeniable that they are billable. In fact, it is necessary to bill for these time-consuming activities in order to assure an adequate supply of physicians for now and in the future. It is part of the process for balancing supply and demand, which is the appropriate term for optimizing access to and availability of care. The difference being that the free market can truly optimize accecss to care, whereas socialism and 3rd party-payers don't have a chance to do so, and indeed invariably lead to imbalance of supply and demand for medical services, and therefore poor access to care.

6. The phrase "If you don't document it, it didn't happen" is a lie.

This concept is foisted upon us by 3rd party payers who don't want to pay. The notion that adding 3 little words to the Review of Systems changes the "allowable" amount for billing is ridiculous.

7. We can entirely dispense with coders.

There is no need for CPT codes, E&M codes, ICD9 codes, JCAHO and HIPAA, as long as we stand up together for a common sense, comprehensible, fiscally rational medical economy. The current medical financial system in America suffers from all the economic failings of socialism, plus all the hassles of innumerable and hated 3rd party-payers. One thing to consider is that it is totally acceptable to bill by the hour if you wish. Lawyers do. Auto mechanics do. Almost everyone does. Billing by the hour allows the patient to be in some control of the cost of a visit by giving them knowledge about costs which in the current system are unknown to them (and often to us as physicians!)

8. Socialized Medicine is completely unacceptable in America.

It is in the long term interest of the nation to say no to socialism. Socialism has failed in the largest human experiments ever undertaken. Millions of lives were lost in those experiments under Stalin and Mao. In some countries, socialism hasn't failed yet, but in those countries invariably the wealth of the nation (people and money) is being rapidly exhausted. Medical Care is too important to condemn to the idiocy of socialism. It is acceptable and indeed may be honorable to not accept Medicare and Medicaid, or for that matter any other insurance in lieu of direct payment to you from the patient. It is also acceptable to provide medical care for free or reduced fees, if you, as the doctor, so chooses. As a physician, you can give discounted prices for the expert advice you provide, if you so wish, to patients, and without obligation to provide the same discounts to others. It is up to you as a physician; it is in your power.

It is unacceptable to force doctors into socialist medicine. If you are one of those misguided doctors who thinks that we should have universal health insurance or fully socialized medicine, the AAdD thinks you are shortsighted, ignorant of history, and we don't want anything to do with you. However, we will make a deal with you. We won't try to use the inordinate power of government to prevent you from socializing your practice, if you don't try to use the power of government to force us to socialize ours.

Free market medicine is the most caring form of medicine, for it allows continued advancement of the science and art to maximally help the current generations and all those to follow. On the other hand, universal health insurance and socialist medicine is billed as caring, but indeed is short-sighted, devastating to the health care of future generations, and, not to mince words, outright idiotic.

9. Patients are primarily responsible for their health.

Lifestyle influences health more than doctors do. If a patient is more responsible for a bad outcome than the doctor (for example, if a doctor makes a delayed diagnosis of smoking-induced lung cancer) then the patient sure as heck should have no legal case against the doctor.

Americans can be smart enough to make their own informed health care decisions, the same way they make decisions about buying vs. renting a home. Some fixing up of the government school system may be needed, but that can be accomplished too.

10. Ignore HIPAA wherever possible.

HIPAA is an insane, complicated and terribly expensive law that would never have been needed had the government kept to its constitutional role and stayed out of the health care business.

If these propositions coincide with your values, please express yourself not with random frustrated squawking that you know goes nowhere, but rather with a coordinated effort with others who share your views. It is time to recover our own self-respect. It is time to take back our Profession. It is time we use what power we have left to fight for what we know our patients will need, now and in the future. It is time for physicians to stop being pushovers and suckers. Having been so for the last few decades has led to potentially irreparable harm to our profession and our patients.

Join the American Academy of Disgruntled Doctors. We are the politically incorrect Academy, with a mission to solve the real economic problems that are destroying medical care in this country. We do what the AMA is afraid to do--speak the truth loudly. We are dedicated and serious.

Join us.