Tuesday, June 24, 2008

“I love being a doctor but I hate practicing medicine”

This New York Times article on doctors' frustrations with their profession couldn't have come out at a more appropriate time. Although I am a psychologist, I do know how these doctors feel. Since I am in private practice, I handle all of my own paperwork for Medicare, TennCare and other various insurance companies and have nearly lost my mind with the mind-boggling paperwork. I spent the morning on the phone trying to track down lost checks, trying to figure out why I wasn't paid the right amount for certain services (too little, of course) and finally, how I could get off insurance panels altogether because I have come to the point of not caring anymore.

What struck me about the article is how most of the doctors mentioned are in their late thirties to early forties. I became frustrated around 37 when I realized that I did not really have the time or energy to chase down payments, beg for authorization and take pay reductions everytime managed care or Medicare decided to cut payments. Now it looks like there will be a 10.6% cut in Medicare on July 1st which has caused many providers to decide not to take it, but I digress. My real point is that by the time you have been in the field for some time, have family responsibilities and understand the realities of the "helping profession" you are now stuck in, you finally realize you may need help yourself.

And it is not just about money, it is the frustration of paperwork and the feeling that you can never get everything done. Many of us who are in healthcare are perfectionists or a bit compulsive. One has to be to a certain degree because people's lives and health are at stake. One doctor in the Times article sums up the problem:

For me it’s an endless amount of work that I can never get through to do it properly,” said Dr. Jeffrey Freilich, 38, a primary-care physician on Long Island. “I’m a bit compulsive. As an internist, I have to worry about working up so many conditions — anemia, thyroid problems and so forth. There is no time to do it all in a day.

“On top of all that, there are all the colonoscopies and mammograms you have to arrange, and all the time on the phone getting preauthorizations. Then you have to track the patient down. And none of it is reimbursed.”


And while for me, it is evaluations and therapy rather than colonoscopies and mammograms, the frustration is the same. Every year I work a little less in my field and turn to other areas to earn a living. But it makes me sad that the field I spent 11 years training for is not the same one I thought I signed up for, and I don't see it getting better. It is disheartening and makes me sad but other than quit, I don't know what else to do.

Update: Shrinkwrapped, it seems, is also having problems with Medicare: "As of the end of December, 2008, there will be one less Doctor participating in Medicare. I doubt I am alone in my disgust and annoyance." No, Shrinkwrapped, I doubt you are alone.

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131 Comments:

Blogger Scottish said...

I don't know, Dr. Helen. I'm an engineer, and I spend more time correcting drawings, reviewing bids, collecting and tabulating data, and other miscellaneous stuff than I do dreaming up new ideas or solving problems. I think it's just part of having a job with a lot of responsibility.

10:29 AM, June 24, 2008  
Blogger Eric said...

I do think it's different scottish - you're not doing all of those things in order to satisfy someone who's looking for any excuse not to pay you.

10:43 AM, June 24, 2008  
Blogger Helen said...

Scottish,

What Eric said. I will add that it would be like you were on the phone or fighting to get paid on each of your jobs for numerous hours per week. Do you do jobs for people and then never get paid? or get paid less than what the job was worth and have no bargaining power at all? In other words, it would be like doing your job by the piece--and having to beg and turn in numerous forms many times to get each piece paid for and often, not getting paid at all or taking less than you thought.

10:44 AM, June 24, 2008  
Blogger TMink said...

Yeah, what other profession do the work, then someone with less training and no personal knowledge of the work decides if they will get paid or not?

Insanity.

Trey

11:14 AM, June 24, 2008  
Blogger bwebster said...

After moving to Colorado, my wife and I went looking for a medical practice for our doctor visits. We found one that we liked, but their first question was whether we would be using an insurance company. We said no (I'm self-employed and am self-insured for basic medical care), and they took us in a heartbeat. What's more, they give us a great discount for our up-front payment in full.

They also said that they would have turned us down if we were using insurance; it's such a pain that they just aren't taking any new patients who use medical insurance. ..bruce..

11:33 AM, June 24, 2008  
Blogger Scottish said...

I didn't get the impression that the article was primarily about payment, but about paperwork in general.

I do see that would be another level of stress. But again, I'm not sure it's unique to the medical field. I imagine many other small business owners spend loads of time chasing payment. I know OUR vendors do!!

I think it's the combination of being an educated professional AND being a small business owner that is unique. You've slaved many years through medical school and you feel like it's a waste of your hard-earned skills to spend time chasing payment. But that's the way small business works. Maybe you could consider hiring an office manager or collection agency? I don't know how practical that is.

11:55 AM, June 24, 2008  
Blogger Shouting Thomas said...

I recently vacationed in the Philippines. Medical and dental care are incredible cheap there and the quality of care is very good. I had my teeth cleaned by a very competent (and very pretty) female dentist for 12 bucks.

Health care is cheap in the Philippines precisely because just about nobody has insurance. Everything is on a pay-as-you-go basis. In the U.S. everything is inflated by the availability of insurance.

I'm current struggling to find adequate insurance... probably will ultimately pay $400 a month. But, I'm putting off two procedures that will cost me thousands of dollars in deductibles. I'm considering another vacation to the Philippines to have these procedures done. I'd probably still come out ahead.

When I retire, I'll probably spend half my time in the Philippines and I'll probably go entirely to the pay-as-you-go system.

People don't sue much in the Philippines either. This is a charming difference from the West. If an overloaded bus goes over the cliff and everybody dies... well, that's just the way it goes. They're dead.

When I returned to the U.S., I wondered if we're not pricing outselves out of sanity.

12:14 PM, June 24, 2008  
Blogger Vicki said...

My doctor stopped taking insurance several years ago. He's an internist and costs me a fortune. Why do I go? He is so incredibly thorough, takes his time, asks tons of questions every visit, and is the kindest, happiest doctor I've ever met. He'll spend 2 hours with me if I need it. He's also one of the highest regarded internists in the city.

The pain is in the wallet because I'm not a well-off person. But its difficult to give up that level of service.

12:57 PM, June 24, 2008  
Blogger Mary said...

I can think of two hopefully helpful suggestions. In the Medicare program, you can opt out, meaning you will be a non-participating provider. Then you are free to set your rates as you will, but will not be guaranteed the government checks to help subsidize your practice. (Meaning if you choose to treat non-privately insured patients, the govt will not provide you with a payment floor for your services.) It might be a bit risky at first, structuring your practice this way, but if you want more control of your office yourself, there is a way to cut yourself lose from the govt paywork paperwork.

2) Consider hiring an experienced office manager. Of course, you may need to document differently than you do now, so there is clear communication between you two, but someone with a business background who understands the ins and outs of the system surely will be more efficient than when the providers try to take on too much. You can then spend more time practicing in your area of expertise, and can provide a part-time job for someone perhaps looking for greater flexibility.

Down deep, maybe you prefer to explore other avenues of income generation (such as online, public relations work?) than to practice full time what you've invested in learning. It might just be, though, that this is harder for medical providers to admit who may have gone in with noble intentions, but found themselves uncomfortable with all the responsibilities the job entails, as scottish above suggested. I think many professions are like that (attorney, teachers, clergy, etc) though, because there is so much emphasis at the outset put on the "helping" aspects of the job and less on the more practical work-a-day world realities.
.........

Then again, helen, it might just be an early onset midlife career crisis you're experiencing pangs of here... Have you tried window shopping for say little red convertibles? Sometimes having something to work for does wonders for getting us through the drudge work necessary to get paid for (and that's your complaint, right? You don't know which ones will pay up on the first request, and which ones you'll be treating pro bono.)

1:30 PM, June 24, 2008  
Blogger P. Rich said...

There is an old Rule of Thirds for the expenditure of time regarding consultants, who are actually small business owner-operators:

1/3 marketing, sales, promotion
1/3 administration
1/3 doing the actual work

Trying to spend 90% of the time doing the interesting stuff and the other 10% of the time on the remaining 67% of the business requirements is bound to lead to frustration and eventual failure - for any number of reasons.

The actual numbers will vary by profession, but think of the above as illustrating a principle. Having to deal with a large and growing bureaucracy whose existence is forms- and regulation-driven will certainly exacerbate the administration figure.

1:31 PM, June 24, 2008  
Blogger orthodoc said...

Scottish,

It's not as easy as simply hiring an office manager. Every MD office has one. On average, there are 3-5 support staff/MD in most offices; one to deal with getting payment, one to navigate EOBs(Explanation of Benefits), and maybe one to actually do patient care.

The basic issue is one of reimbursement. Medicare and Medicaid both reimburse at a level where it is literally impossible to make ends meet; often, the taxi service bringing the patient makes more than the MD.

Private payers typically reimburse at a multiple of Medicare, such as 120%; so the hit isn't quite as bad. Opting out of Medicare is frequently not an option; hospital credentialling and other health plans may require that you be a Medicare provider, and the documentation for both opting out and back in is onerous in the extreme.

By the way, I can think of no other endeavor where the seller of services is routinely expected to provide 50-75% discounts, and then provide additional services for free.

2:08 PM, June 24, 2008  
Blogger Joe said...

Not a doctor, but ran my own software/media production company for a while. The amount of government paperwork required for just normal business operation was astonishing, and I was just one person. I even wrote to my senators and congressmen and essentially told them that if they really wanted to help small business, they could reduce the government imposed bureaucracy. (Since then, our politicians have just made it worse, like with Sarbanes-Oxley.)

2:13 PM, June 24, 2008  
Blogger BobH said...

The payment issues that the doctors are complaining about are inherent in situations where the person paying for the benefit (i.e., medical care) is different than the person receiving the benefit. In those situations, neither the provider nor the receiver has any particular incentive to keep costs down. Only the payer has that incentive.

2:18 PM, June 24, 2008  
Blogger P. Rich said...

Helen,

I don't know that my earlier post was of any value to you, so here's a possibly useful addition:

1. Analyze the time division of labor specific to your circumstances.

2. Recognize that everything is work driven, i.e., the amount of "actual professional work" you do drives administrative and promotional requirements. Perverse, but true.

3. Reduce the driver - actual work - to a level that allows the total time demand to be personally acceptable. This will relieve one type of stress.

However, there are obvious negative consequences to this approach which include reduced income and less time spent doing what you really want to be doing.

A partial remedy is to hire appropriate help for the non-work-specific chores. This adds costs, of course, so it introduces various related trade-offs.

Another option is to partner (or join/form a shared business overhead support group of some sort) and realize resulting efficiencies, for example by sharing outsourced administrative resources and thereby reducing individual member time and monetary investments. Keep in mind that there are real opportunity costs, in actual $$$ terms, associated with your time spent doing admin paperwork - thus making you an expensive, hugely over-qualified administrative aide to your business.

In short, try looking at yourself as a business and at the situation as a business problem first, then seek business solutions that support pursuing your true professional interests.

3:26 PM, June 24, 2008  
Blogger Helen said...

Orthodoc,

That is exactly the problem I am having. I would love to get out of Medicare but it will limit the places and settings that I will be able to work in. I have thought of opting out of Medicare but getting in was hard enough and I would have to reapply which would be tough, but not impossible. I guess I am tired of the paperwork, the hassle and the pay. I love the clients and the work though.

P.Rich,

Thanks for your suggestions, they are most helpful.

4:01 PM, June 24, 2008  
Blogger aphron said...

This comment has been removed by the author.

4:28 PM, June 24, 2008  
Blogger aphron said...

As an optometrist, I'm right there with you. There is no fix. Silent Thomas hinted at making everything private pay. That would bring down the costs of healthcare. The side effect would be less practitioners. The incredible stress of taking care of a person with the added stress of paying back student loans would drive many out of the industry and keep others from pursuing it. Practitioners are caught between a rock and hard place.

I'm 39 years old and have been practicing for 13 years. Burn out is fast approaching. The decreased payments are part of the game, so I expect that. The problem is the patient. He/she does not value the care given. Since the patient does not really pay for it, it is taken for granted. This same patient will raise holy hell, if payment is denied and receives a bill. Suddenly, the practitioner goes from being the greatest saint to have ever lived to a greedy money grubber.

Healthcare is the one profession where everyone assumes the provider of the care doesn't have bills or expenses. My staff like a paycheck at the end of the week. The plumber may get stiffed, but he isn't expected to eat it because he's a plumber.

4:31 PM, June 24, 2008  
Blogger Cas said...

Please understand that I'm NOT a health care provider, but I work with many of them.
Is there any way to reduce or eliminate the "BS paperwork" AND still prevent the enormous amount of Medicaid / Medicare fraud that is frequently discovered?
Would trying to automate as much of the required paperwork be part of solution, or would it be worse?

4:52 PM, June 24, 2008  
Blogger Mike Wilson said...

Ya know, this sure sounds like nothing so much as a business opportunity to me. Fortunately I'm not that much of a masochist myself. But there's got to be some kind of service that will wrap up this administrivia for you.

Or isn't there?

5:19 PM, June 24, 2008  
Blogger P. Rich said...

-mike wilson-

My brother is an architect, and he has a friend whose business is providing bundled services to architects - bookkeeping, billing, notices, collections, deposits, tax filings etc. I don't know if such a (more specialized) service is available to health care providers, but I agree with you that it looks like a business opportunity for someone.

6:02 PM, June 24, 2008  
Blogger Mary said...

P rich-
Many practitioners invest in a billing service that handles all of the government billing and probably knows the ins and outs of the paperwork better than many solo medical providers. Well worth it to know when to contract out where you don't have the expertise to navigate the system. Changing the system via complaints... sorry, I don't think that will garner you much change or much sympathy.



I suspect helen's money woes and complaints are more of a temporary nature -- I recommend a good soak in the hot tub, a nice glass of wine (that's singular, note...) or perhaps a quick vacation getaway. It's summer, prices are up, and we all get stiffed every now and then in our work. No need to bang your head trying to change the overall system that's only trying to prevent fraud -- gets like that when things get so big, which of course benefits the good majority of us financially. Ask Glenn to explain if you're still not seeing it. And remember, nothing wrong with making a career change voluntarily, and no need to make an excuse to pursue more of the side opportunities while choosing to practice less and less.

9:07 PM, June 24, 2008  
Blogger David said...

It's true that many professions go through similar stresses. When I worked as a system administrator, they passed Sarbanes Oxley and suddenly I seemed to be spending all my time doing paperwork instead of administering systems. It was frustrating and stupid.

One enormous difference: The stakes weren't very high. If a server crashed the business might lose money and I might lose my job, but no one was going to die.

Health care has all the usual small business problems plus an unusually high level of government meddling, PLUS very high stakes responsibilities for people's lives.

It would be too much for a lot of people. Helen, I know in your line you deal with very scared, messed up and maybe even scary people. I can't blame you if you do decide to throw in the towel one of these days but for now, thanks for hanging in there.

11:15 PM, June 24, 2008  
Blogger Helen said...

Mary,

The problem is bigger than one practitioner complaining about the system. As the Times article says, doctors are leaving the field or not going into specialties where they are desperately needed such as primary care or internal medicine or subfields like gerontology. All of us need more people going into these fields, not fewer and if regulation, reimbursement, and overwork is keeping people from entering or causing practioners to flee, suggesting a glass of wine and a soak in the tub is naive as well as ridiculous.

David,

Thanks for your kind words.

6:15 AM, June 25, 2008  
Blogger parapraxis said...

In my practice as a clinical psychologist, I am not a member of any provider panels and do not accept Medicare. It's just not worth it for the hassle to me, but it's even more important than that. My patients pay me when services are rendered...the full fee. For the probably 40% of my patients who want to use insurance, I pay someone on a monthly basis to use some billing software once a month and to go through my appointment book for the month to put the appointments in. She prints out the claim forms and sends it in. I inform my patients ahead of time that if they use insurance, it may or may not cover my services. You really have to find a way to run your practice that reduces the headaches that paperwork entails, or it will take the joy out of what you do. If you are on a provider panel, you no longer work for the patient, you were for the insurance company. That's unacceptable to me. You can have a successful practice and freedom from the pain you are having now. There may be other ways to do it..this is just the way I have done it.

6:51 AM, June 25, 2008  
Blogger Mary said...

Helen,
Perhaps I have a bit more confidence in the numbers of young people coming up behind you.

No need for namecalling now... I understand your midlife stresses. Just suggesting that the change lies with you, not with the system. Surely you'll burn yourself out faster taking that path, and complaining rarely solves anything.

Try creativity -- if you don't like working with pro bono cases (or deadbeats, if you prefer) you really ought to invest in a billing service, office manager, or someone more competent in negotiating the system. Calling up and moaning at the Medicare reps is not going to work -- surely better people than you have tried, and even with your family's blog influence, I think you're more likely to improve your own mental health if you step away for a bit, and relax some, and think more about your future options.

Again, I think of all the wait staff that gets stiffed ... all the 2-parent income households working together now to make ends meet for rising costs ... all the folks who are damned lucky to have Medicare coverage at all in this country...

I'm sorry. You're troubles don't really seem so large, nor do your cares indicate imminent collapse of the gov't programs. Remember those young people ... The more realistic you are going in to the helping professions, and the less you are doing it to get mega-rich, the more likely you won't burn out mid-career and begin exploring newfound opportunities. Not that there's anything wrong with that -- you're very photogenic, and I'm sure there are other opportunities if your permit yourself to choose them and not feel guilty about it.

Make it a great day, helen. And don't try to be a white knight out to save the world. That's exhausing surely?

7:14 AM, June 25, 2008  
Blogger Helen said...

Parapraxis,

Great suggestions, thank you. How do you handle low income patients who cannot pay? I deal with courts and attorneys who refer those with legal problems to me who often are without jobs or without any way to pay for treatment other than insurance.

7:22 AM, June 25, 2008  
Blogger Sylvain Louradour said...

Dear Dr Helen,

I collect people's favourite places on my blog http://yourlovelyplaces.blogspot.com/

and I'd be very pleased to receive a photo of yours.

lovelyplaces@hotmail.fr

Best regards
Sylvain Louradour

9:23 AM, June 25, 2008  
Blogger David said...

There have been some successes in the application of "lean" management techniques to healthcare, both patient care and administrative aspects. Mark Graban, who has a manufacturing background and now works mainly in healthcare, has an interesting blog and also has a book out.

Here's his interview with Dr Sami Bahri, "the world's first lean dentist."

9:28 AM, June 25, 2008  
Blogger Zed said...

I left the profession more than 20 years ago for the very reasons you mention.

9:41 AM, June 25, 2008  
Blogger Jamie Irons said...

Helen,

This is an extremely important issue, which it is difficult for those outside the "helping professions" to understand.

(Full disclosure: I am the chief of a large department of psychiatry for Northern California Kaiser, a senior physician in The Permanente Medical group. Ninety percent of my work is consulting in a large general hospital with internists, surgeons, and multiple kinds of specialists. Working where I do, I do not have to struggle directly with billing; our struggles are with government agencies, regulators of every stripe.)

A while back I formulated what I call the "Three Ironclad Laws of the Medical Marketplace":

(1) Everybody seeking medical services wants everything, from cosmetic surgery to cardiac catheterization.

(2) Everybody wants these services for free or (what amounts to the same thing) everybody wants someone else to pay for everything.

(3) Anyone under thirty who does not yet have a family thinks he is immortal.

These "laws" are deliberately formulated in an exaggerated way, to make a serious point.

Third party payers, whether private insurers or government programs, fail to address, and in fact further aggravate, the economic distortions introduced by the "three laws." Practitioners struggle to get paid, fill out reams of repetitive paperwork, and are underpaid, because the payers don't really have the money, and don't really want to pay for, all the demanded and/or desired services. That is why, as one person commented above, it is so easy to get a private practice physician to give you services if you are willing to pay up front: you know what you want, and you are willing to pay for it.

The problem of caring for indigent patients is a very thorny one, which cannot be addressed, in my view, successfully by any government program or agency. They inevitably introduce too many "three laws" distortions.

I am very sorry, by the way, to read that you are gradually being driven away from your practice; that is a terrible loss to your patients.

Jamie Irons

10:55 AM, June 25, 2008  
Blogger Doc Paul said...

Helen:

I sense a disturbing lack of appreciation for what we health care providers are going through. While I appreciate the suggestions that some have made, those making them need to realize that what works for a dentist might not work for a pathologist or a clinical psychologist.

What disturbs me, though, is that when I went through college (graduated in 1985), all of my father's (a surgeon) colleagues - without exception - discouraged me from pursuing a medical career. The trends that were in place 25 or so years ago portended a bad practice atmosphere, or so they said. They were right, but I didn't listen. However, I have four kids of my own, the two oldest of whom are twins entering their junior year of high school. I have told them in no uncertain terms that I do NOT want them to go to medical school (my wife/their mother is also a physician).

There will be a brain drain away from the caring professions unless something substantive is done about tort reform, about reimbursement, and about the hassles of running an office. For those who think that universal health care is a panacea, I can assure you that the mere threat of it is why I am digging in my heels with my own kids on this, and why thousands of kids like them (great grades, great kids) will be doing something else. And then who will provide the health care? No billing agency can fill that void.

11:01 AM, June 25, 2008  
Blogger Billy said...

Off topic,

But on the front page of Fox news' website is a video article about a woman who was the family breadwinner and is now paying her husband alimony. The irony is the whole thing is played off like it's an injustice to the woman paying, and they go so far as to title the story "Manimony". The male interviewers are shocked at the notion that a woman would ever have to pay her husband alimony, they blame him for not having a job (despite he's always been the one who stayed home to take care of the kids), and ask her to stick around after the show so she can be given some advice that will get her out of paying alimony.

If only men who were paying alimony got the same sort of treatment. Why am I not surprised that when it starts to become more common for husbands to be the caretakers that society doesn't think they're entitled to the same social support systems as women?

11:13 AM, June 25, 2008  
Blogger Jamie Irons said...

Doc Paul,

Like you and your spouse, my wife (also a physician) and I have four children, in our case all sons (the two youngest being twins).

We also discouraged our boys from becoming doctors, (or I should perhaps say did not encourage them to become doctors). In fact, they all went into engineering (two mechanical, one electrical, one computer).

I could not agree more with all you write.

Jamie Irons

11:17 AM, June 25, 2008  
Blogger Doc Paul said...

jamie irons:

Interesting symmetry in our family lives! I think the comment that was the proverbial straw that broke the camel's back was the one about getting a red convertible.

This isn't about some isolated psychologist in Knoxville going through a midlife crisis! I have honestly started thinking about getting a law degree through a night school program, so that I can bail out if and when single payer becomes a reality and all that I am left with after many years of schooling and advanced training is a salary decided by the likes of congress critters.

When I was 16, as my oldest kids are now, there was still a certain mystique to medical practice. Just getting into medical school was considered a feather in one's cap, and getting into a prestige school (as I did) was a big deal. That was the perspective from outside the profession that made it attractive to me despite the naysaying of my father's colleagues. That is history, folks. And when you need care and the smart kids have all decided that they can make a career out of something less vexing than medicine, drinking a glass of wine or buying a convertible ain't gonna help anybody.

11:26 AM, June 25, 2008  
Blogger Jamie Irons said...

Doc Paul,

Yes, the "red convertible" (shall I say) motivated my response, too.

Those who don't have to deal with the frustrations of modern medical practice may (to some degree understandably) have trouble sympathizing with physicians, who are expected to be selfless and dedicated and not to complain too much. (Such expectations, in my experience, are very often met!)

But the problem goes beyond mere complaining, and beyond proposed "solutions" that merely argue for more help in the office to take the burden of paperwork off the harried practitioner. After all, the fillers-out-of-forms have to be paid somehow, too!

The only solution that will work will have to start from an honest recognition of what the true costs of desired services are, and who is going to pay for the services (see my "three laws" above).

And that is something I just don't think we, as a society, are yet mature enough to take on.

Jamie Irons

11:45 AM, June 25, 2008  
Blogger NJArtist said...

To what extent can your paperwork be computerized? Is there a software package out there that will do it for you? Can you, or someone you hire, create an MS Access database with a form for entry, tracking, and printing reports(and labels)?

11:48 AM, June 25, 2008  
Blogger David said...

doc paul..."what works for a dentist might not work for a pathologist or a clinical psychologist"...of course, and no one is saying it necessarily would. But there *are* many things that people in one field or subfield can learn from people in other lines of work...if a dentist can learn from Toyota, maybe people in other specialties can, too.

12:05 PM, June 25, 2008  
Blogger Jamie Irons said...

NJArtist,

This is not a satisfactory or complete answer to your thoughtful question, but the other day I emailed Glenn Reynolds about one of the limitations of software solutions to "the problem" as follows:

Glenn,

Your thoughts on the Sandeep Jauhar piece put me in mind of a change we are having to deal with in Northern California at Kaiser. Our electronic medical record system (EPIC, known as "HealthConnect" at Kaiser) is being modified so that physicians can do what is call "E & M coding," which basically records and rationalizes everything that a doctor does so that billing can be made (it is hoped) more rational and more easily subject to audit.

The jobs of primary care physicians like internists, family doctors, and others, are already extremely difficult. This added burden on their work (about two or three minutes per fifteen minute visit) may turn out to be the last straw for many.

It seems to me that one major motivator of this change in practice is the need to satisfy third party payers (in Kaiser's case, mostly MediCal and MediCare) that they are getting what they pay for. That is all well and good, but I have to wonder whether the same goal might not be accomplished more efficiently, and with less pain for the physicians, if the patients were in direct control of how and where their health care dollars were spent.

[end of quoted material]

Again, I think the problem is not so much paperwork, or the filling out of forms, whether in paper or electronically. It is the market distortion introduced by regulating agencies (some of whose functions are indeed necessary), third-party payers, and our own refusal as "consumers" of health care services to honestly face the costs.


Jamie Irons

12:12 PM, June 25, 2008  
Blogger David said...

the problem is not so much paperwork, or the filling out of forms, whether in paper or electronically.

Bingo! What happens to the software that was supposed to solve your problem when Congress changes the regulations?

Someone like me who charges an arm and a leg just to think about your problem then has to update the software. The updates have to be tested and installed. As like as not, someone has to be trained in how to use it. If it goes down for any reason (which I've seen include an Internet outage) your office is essentially shut down.

And even after the software is tested, there might still be unforeseen bugs. It never happens with code I write of course, but I've heard that bugs can happen (yes, my tongue is firmly in my cheek at the moment).

And THEN, Congress changes the regs again next week.

Software is just a patch to a crappy system created largely by people in Washington who think that if they can just control things tightly enough, no one will notice what complete idiots they are.

12:26 PM, June 25, 2008  
Blogger Joe Martin said...

I actually work for Epic, supporting our clinical billing system. I help our customers figure out the best way to use our features to manage their billing. As I discuss with billing with them, I'm continually amazed at just how much effort it takes to collect money.

Helen, I have every sympathy for you and your struggles. We work only with the biggest hospital / clinic systems in the company. They have fully staffed billing offices and still struggle to collect all of the money that they're owed. They spend a tremendous amount of time checking that all of the billing codes, diagnosis codes, supporting documentation, and much minutia are correct on claims that they send out. I can't imagine doing all of that work while simultaneously trying to actually provide patient care.

It is, I think, simply unbelievable how much overhead is involved in the medical industry. That is, unless you've seen it you won't be able to believe it.

Medicare has low overhead because it pushes the overhead down to the doctors. Medicare claims better be perfectly formed -- if not, Medicare will simply deny the claim and force you to fix it until it matches their requirements. (Note: this doesn't necessarily mean that they check anything, just that they require the forms to be perfectly filled out.)

For the sake of the organizations I work with, I'd like the U.S. to move to a fully self-pay system. I'd be happy to eliminate my job and move to another area of the company.

12:35 PM, June 25, 2008  
Blogger parapraxis said...

Helen wrote:

"Great suggestions, thank you. How do you handle low income patients who cannot pay? I deal with courts and attorneys who refer those with legal problems to me who often are without jobs or without any way to pay for treatment other than insurance."

Well, I'm not in that kind of situation. Generally, it's established through when they first call for an appointment, and my fees and policies are explained. If they cannot do this, I will on occasion offer a discount. On very rare occasions, I have let them just pay the co-pay, but I stay away from that as much as possible. Often it's discovered in the initial call whether they will be able to afford my services or not. If they have medicaid or medicare, or no funds, I refer them to the local mental health center.

Quite frankly, the mental health center is better set up to help a person in a situation with no job and no money than we are in private practice.

The only court work I do is on court-ordered evaluations where the court pays. I've done evaluations for court-ordered treatment and recommended treatment through a mental health center. On occasion, I have done the treatment myself if they can afford it and it was appropriate.

Part of the sad thing in the field is that we can't help everyone, but there are options for those who cannot afford our services that may be better suited to their overall needs and situation.

So, I would think you might need to re-organize things a bit with your referral sources. Maybe the first session or evaluation should be to determine the most appropriate treatment given the individual's life and financial situation. That is, if you can't work it out on the front end before you even see them.

It's good to have a steady and reliable income from a certain source, and then you can shape the rest of your practice to be exactly what you want. I do social security disability evaluations one day a week, and that pays the bills. There is no billing that's done with that, and they pay quick. The rest of my practice, I shape it to be how I want it. You can't help everyone, but there is help out there for everyone who wants it...it just may not be with you.

You might be better off establishing a lower overall fee if you start to do this. Frankly, you'll probably get paid just as much in the end, because you will get the money and not have to haggle with insurance companies.

If you're to the point of wanting to close up shop because of this, I'd drop all the insurance panels and drop medicare completely. And completely re-organize everything so that you can feel in control of your practice instead of feeling controlled by insurance companies. Anyway, that's what I would do... Feel free to email me privately if you'd like.

12:53 PM, June 25, 2008  
Blogger Mary said...

For the record, I made those red convertible/red whine suggestions. Thought it honestly might help helen to take a step back here, particularly with her heart and stress levels.

For the record, I work in Medicare Financial and have a strong understanding why we do need to regulate the system as it exists and made some quite helpful suggestions that other medical providers have found work successfully.

If the "woe is me" theme is contagious, no great loss to the profession. There are still plenty of providers able to provide care, navigate the financial system, and make an honest living. Can you imagine the fraud we'd see if these things weren't documented and the procedures were thrown to the wind.

I sympathize, but that's the current system, folks. Take it, leave it, be creative and work within it. But really, don't expect the medical field will fold without your services. If you don't like treating poor folk, try better client intake screening procedures or hire someone to help you. And really, have a glass for that whine, helen...

1:25 PM, June 25, 2008  
Blogger P. Rich said...

There are a number of comments here which reduce to: fix the government.

Sorry. Not going to happen in this lifetime or the next. It may turn out that individual practitioners eventually go the way of family farms (giant agribusiness effect)and small local stores (shopping mall and Walmart effects).

Healthcare is not a noble cause, it is a business segment - or if you feel strongly, perhaps it is both. And like all business segments, those who choose to participate in it have to function within conditions specific to that segment. Hoping that onerous conditions will magically become less so is, well, magical thinking. More likely is that negative conditions will only worsen.

So, it may be that bureaucratic overhead for many individual practitioners is just too burdensome, and the problem may not be correctable within traditional operating models. That truly would be a shame, and at the moment I can see only three typical options:

1. Leave the field altogether, possibly transferring [some] knowledge and skills to another field
2. Consolidate
3. Create or size down to a profitable (or non-profit), highly specialized niche with acceptable working conditions.

Good luck.

1:32 PM, June 25, 2008  
Blogger Neal J. King said...

I hate to bring up the specter of creeping socialism, but I live in Germany, and EVERYBODY is insured, one way or another.

The secretary just takes your insurance card when you walk in, gives it back, and you're pretty much done. They don't have a lot of people in a back office squirreling around trying to deal with getting payments from various insurance companies, because the companies have to sign up to standard coverages and policies.

The doctors seem focused on doing medicine, take time for questions, and don't rush around.

I'm going back to the US someday; and the one thing I'll worry about is getting adequate health coverage. I remember what that was like from the patient end, and I heard enough from the doctors & staff on their end, as well. Technologically, US medicine is great; but as a system of coverage, it sucks. I think a single-payer system, with an option to pay more for higher-priority coverage, would work, and bring the U.S. to something approaching the German level.

But it'll never pass as long as the insurance companies can keep fooling people about the complexity, socialism, etc. Instead, we'll keep the profit motive in the driver's seat, and the insurers & HMOs will keep squinching down on doctors and patients.

1:42 PM, June 25, 2008  
Blogger Doc Paul said...

Mary wrote: If the "woe is me" theme is contagious, no great loss to the profession.

Mary - When you are in need of care, and there is no one there to give it, or at least no one of the skill and compassion of those who used to populate the field, I hope you remember your words and wonder why my son the engineer and my daughter the veterinarian aren't there to help you.

With all due respect, Mary, I really can't believe that response, but I suppose, as in many things, until the cataclysm comes, no one really looks to solve the problem.

2:23 PM, June 25, 2008  
Blogger Jamie Irons said...

Doc Paul,

Mary's supercilious and overbearing tone perfectly encapsulates why physicians despise government agencies and their associated bureaucrats.

She wrote:

"Can you imagine the fraud we'd see if these things weren't documented and the procedures were thrown to the wind."

A few years back, a group of con artists in southern California started ordering drugs fraudulently under my name and charging them to Medicare. The agency sent a list of some 500 or so names of people whose prescriptions I had supposedly written, none of whom I had ever seen. This had gone on for three years before Medicare discovered it and reported it to me, and though I asked them repeatedly for follow-up, I never got it.

Quis custodiet ipsos custodes?

Jamie Irons

3:14 PM, June 25, 2008  
Blogger David said...

Mary...systems exist for people, not people for systems.

3:19 PM, June 25, 2008  
Blogger Donna B. said...

As a patient I worry about good medical care not being available when I need it.

I'm currently insured by Tricare, and because I live near a military medical facility that's where I go for my care.

I have seen only a physician's assistant for the past year. Now, I think she's great and a very caring person who will refer me to outside specialists quickly if needed.

However, sometimes it's almost impossible to get an appointment to see her. As the dependent of a retiree, it bugs the crap out of me to think active duty members and their families are going through the same hassle.

So, I very much do not want to see "socialized medicine" come to the U.S.

My son, disabled since childhood, relies on Medicare. He is currently without medication because he could not get an appointment with a psychiatrist or family practice doc before his prescriptions ran out.

As for the doc who refers such people to the mental health clinic, they won't take my son because he does not have medicaid. Having Medicare disqualifies him.

I certainly sympathize with the providers here. And I've seen enough screwed up claim forms to know that hiring someone competent to do that sort of work is not going to be cheap.

However, I must remind you all of the law of unintended consequences -- health insurance was invented by doctors (and hospitals) so they could get paid more consistently!

It worked fantastically. One can trace the increasing pay and status of doctors with the rise of insurance coverage. At least you're not getting paid with chickens and bushels of corn these days ;-)

I'd say that like a lot of other things introduced nearly 100 years ago, that health insurance has grown into a beast. I'm encouraged a bit by the debate going on, but I'm fearful that it's going to result in single payer.

3:37 PM, June 25, 2008  
Blogger br549 said...

How's the new round of meds doing, mary? They are at least making you a bit more subtle these days.

3:44 PM, June 25, 2008  
Blogger ck said...

I think some outside of the profession can't appreciate the insanity of CMS coding. For example, if you have a 90 y/o patient lying in a hospital bed dying of pneumonia, your payment is cut 77$ if you do not record a family history. That's right: for not filling in a box that has absolutely no bearing on the patient in their condition, your pay gets cut.

The Happy Hospitalist has a running series on this.

http://thehappyhospitalist.blogspot.com/2008/06/it-started-during-adulthood.html

http://thehappyhospitalist.blogspot.com/2008/05/coding-clinic-99233.html

It's really become a series of hoops that you have to jump through in the right order to get paid. More time is spent jumping through hoops than with the patient. The focus of health care now is more directed at "did I jump through the right hoops in the right order" instead of the patient.

Mary, students go to medical school with the explicit desire to practice medicine, not jump through hoops. When primary care consists more of hoops, why would any go into it? Take the path of fewest hoops and highest pay for that is what CMS hath wrought on medicine.

3:51 PM, June 25, 2008  
Blogger Larry J said...

Mary's attitude is a great example of the problem. Her idea of a solution is to drink some wine and buy a sports car. I wonder if she will ever realize just how despised she and the people like her are. We all have our "Marys" to deal with. They are boils on the ass of society.

5:35 PM, June 25, 2008  
Blogger Richard said...

Heavens, those poor doctors have to do paperwork and have to actually wait to receive payment for services. Whiny doctors are only the latest group of Americans to cop an entitlement mentality. I'm not giving the bureaucrats a break here. They are inefficient and a pain in the neck. But please, doctors threating to leave the practice because the effort is too burdensome for them? I have little sympathy.

6:07 PM, June 25, 2008  
Blogger Joe Martin said...

richard -- Doctors have a very legitimate reason for being burned out. It's not just "paperwork". Insurance companies, Medicare, and Medicaid require an insane amount of documentation before they'll reimburse for the work a doctor has already done. See ck's comment above for a very real example.

I hate the entitlement mentality too. This isn't it. This is the "why should I bother working if I have 100% overhead" mentality. I don't think anyone outside the medical industry is willing or able to believe the level of documentation that's required for the medical industry. And, like ck tried to point out, most of it is completely unnecessary documentation.

Might I also submit that ridiculing doctors for their (quite reasonable) aversion to this kind of overhead is not the best way to encourage them keep their practices open? You can feel that they're merely copping an entitlement mentality. But I'll feel that you're merely copping an entitlement mentality when you can't find a doctor that will treat you under those conditions.

6:29 PM, June 25, 2008  
Blogger Mary said...

br549 said...
How's the new round of meds doing, mary?


Cap that M, br baby... And remember, just because it's all the rage to pop a pill and make your troubles go away these days, doesn't mean everybody's on board that boat. Lol

7:03 PM, June 25, 2008  
Blogger Mary said...

David said...
Mary...systems exist for people, not people for systems.


Lol. Gotta love that bumper sticker mentality. That and a dollar'll buy ya a soda these days...

The system is what it is. You can bang your head and whine, or you can study other successful providers and figure out how they manage to balance competing priorities and continue practicing. If, of course, that's the provider's underlying desire. I do question whether helen's heart is still in counseling the mens' rights victims, particulaly the lowrent ones. Something tells me that would get might depressing and draining, especially when there are more and more media and "fun" opportunities surely opening up for women like helen in her field. Nothing at all wrong with making a career change, or better yet, incorporating your interests and getting into a line of work you find more profitable and fulfilling. Just don't imagine the whole helping profession thing is doomed because providers are regulated and asked to extensively document the treatments they are providing and receiving taxpayer money for, if they don't opt out of that system.

7:08 PM, June 25, 2008  
Blogger Mary said...

When you are in need of care, and there is no one there to give it, or at least no one of the skill and compassion of those who used to populate the field, I hope you remember your words and wonder why my son the engineer and my daughter the veterinarian aren't there to help you.

Lol. Is it brag time? Maybe my sister and brother the engineers, my sister the nurse practioner, or my brother-in-law, the IT guy at a big pharmaceutical company can provide me a decent medical referral. That is, if all those poor doctors aren't out digging ditches because they just couldn't make ends meet dealing with the onerous Medicare requirements. Lol.

7:11 PM, June 25, 2008  
Blogger Mary said...

The agency sent a list of some 500 or so names of people whose prescriptions I had supposedly written, none of whom I had ever seen. This had gone on for three years before Medicare discovered it and reported it to me, and though I asked them repeatedly for follow-up, I never got it.

Quis custodiet ipsos custodes?

Jamie Irons


Wow Jamie. Three whole years and you didn't catch a whiff of any trouble there on your own?? Hmmm... I'd say it's a good thing MC spotted the fraud and put an end to it. Remember, they're not there to safeguard physician's identities, scrip pads or to reconcile your internal billing records.

Sorry but if you offered that one up as an example of how MC is failing by catching such fraud, or if you're complaint is they should have caught it sooner (how exactly do your propose that, btw -- by micromanaging your lists of patients and making sure the 500 really and truly got their meds from you??) that's pretty laughable.

The sense of entitlement in here reeks, and this is from the people who supposedly want less government. It's called "non-participating" and opting out is very easy. Or else, hire a billing service or get into a group practice. I agree with the man upthread who said the days of the solo practitioner are going the way of the family farmer...

7:19 PM, June 25, 2008  
Blogger Cham said...

Doctors complain a lot these days about all those forms, the oversight and the waiting-to-get-paid. But if Medicare didn't feel it could get away with reducing fees by 10.7%, it wouldn't be implementing the new payment program. The bottom line is that someone is filling out the forms and waiting patiently to get paid. It might not be a Harvard trained physician with 50 years of experience and a practice in the high rent district but there is some schmoe out there that doesn't mind the extra work. Government paid medical care becomes an active participant in the capitalistic arena of supply and demand. Is that such a bad thing?

7:32 PM, June 25, 2008  
Blogger ck said...

Mary:No need to bang your head trying to change the overall system that's only trying to prevent fraud.

Heh, if ONLY Medicare could make a half-hearted attempt at that! The Medicare system is riddled with fraud -- to the tune of $60 BILLION a year.

The basic premise of CMS and the coding hoops is to increase paperwork in an attempt to decrease payment. This is what happens when a goverment entity realizes it has promised more benefits than it can afford to pay: it bilks the taxpayers for more money or shafts the providers for less.

The overall system does need to be changed. It is horribly inept and harms patients far more than it harms physicians. The amount of money that is wasted due to CMS inefficiencies and regulations is mind-boggling. Private insurers are no better, but care to venture a guess where they get their lead from?

Physicians are culpable to some degree: they and their "leaders" allowed themselves to be painted into a corner. We're already seeing the effects of this folly: less than half of Family Medicine Residencies are occupied by domestic medical graduates. What does it say for the state of American medicine - a knowledge based industry - when it needs to poach physicians from poorer countries?

8:10 PM, June 25, 2008  
Blogger leishman said...

Mary, let's agree that Medicare/Medicaid are rife with overbilling, fraud, and graft and that controls are needed. Let's further agree that you bring integrity to your job and that you do it as best you can. OK--it's your payday, and you have bills in your mailbox. But instead of a check, your "pay" envelope contains an EOB denying half your wages as excessive, and requiring you to submit additional paperwork for the other half, which you may or may not receive in another 30 days. How long would you continue in your job?

8:23 PM, June 25, 2008  
Blogger David said...

But if Medicare didn't feel it could get away with reducing fees by 10.7%,

Umm ... You do know that Medicare isn't just another agent in a free marketplace, right? It's an arm of government, making rules that others have no choice but to accept and for which it has at best minimal accountability.

If you or I - or even an insurance company - simply refused to pay the whole bill, doctors could sue for the remainder. They have no such option with Medicare. They just have to swallow it.

Neither you or I would be thrilled with that situation either.

8:58 PM, June 25, 2008  
Blogger br549 said...

Well, insurance and Gov't won't / don't pay the full amount a hospital / doctor charge. Only the uninsured have to pay that amount. Been there, done that. I am still getting hounded about it by hospitals and doctors. Will be for years to come. My home phone is never answered. It is a fax and answering machine. I listen, laugh, and delete. I pay what I can, and that's all I can do.

9:20 PM, June 25, 2008  
Blogger Richard said...

Might I also submit that ridiculing doctors for their aversion to this kind of overhead is not the best way to encourage them keep their practices open?

Joe Martin-- We will not run short on doctors. The job is still considered to have some prestige and (primarily) for that reason folks are still lining up to get into medical school. For every established doctor who leaves practice, three are waiting to take that place.

Another thing. You will find that the future belongs to those doctors who not only are good doctors, but who understand patient service and the business of medicine. Gone the way of the Model-T will be the ones who thought the word "Doctor" before their name was the only requirement to the gravy train. The legal profession has already gone through this evolution, with mostly positive results for clients. Now it's medicine's turn to evolve.

9:29 PM, June 25, 2008  
Blogger parapraxis said...

All I can say is, that if we get universal health care in the US, I will opt out as a provider of services. If I can't do that by calling myself a clinical psychologist, I'll start calling myself a "life coach," and be 100% self-pay.

I worked at a VA before. I know the quality of care provided in a bureaucratic system. It frankly sucks. Just ask the veterans. The best doctors get paid the same amount as the worst doctors. That is a system that will never ever work in a way that is in the best interest of patients. Is it better than nothing, probably, but that's about it.

So, my thinking is, you set up your pratice where you don't belong to these provider panels and see folks who have the ability and motivation to pay for your services. If your car breaks down, you don't expect the government or insurance to pay for it. But if it's your physical or mental health...that's a right. Your physical and mental health are much more valuable than a car or house or all the creature comforts in life, but too many have come to expect those things without significant committment.

9:50 PM, June 25, 2008  
Blogger Jamie Irons said...

Mary wrote:

"Wow Jamie. Three whole years and you didn't catch a whiff of any trouble there on your own?? Hmmm... I'd say it's a good thing MC spotted the fraud and put an end to it. Remember, they're not there to safeguard physician's identities, scrip pads or to reconcile your internal billing records.

"Sorry but if you offered that one up as an example of how MC is failing by catching such fraud, or if you're complaint is they should have caught it sooner (how exactly do your propose that, btw -- by micromanaging your lists of patients and making sure the 500 really and truly got their meds from you??) that's pretty laughable."

***

I work in northern California. All my patients are Kaiser patients in northern California.

It was my name and my California license number that were being used, not my prescription pads. This was a form of identity theft. The patients may as well have been in Romania. As a Kaiser physician, I have no way of getting any feedback about fraudulent use of my name by some party or parties in a distant part of the state, that are not getting their prescriptions filled through our system.

Medicare was the party being defrauded, in the sense of losing money to the fraud perpetrated through the abuse of my name.

I thought it was telling that they never got back to me with any explanation of how this had happened, or exactly what had happened.

Jamie Irons

9:50 PM, June 25, 2008  
Blogger ck said...

Richard: For every established doctor who leaves practice, three are waiting to take that place.

That is only partially true. For a high demand practice such as dermatology or plastic surgery there are numerous physicians waiting in the wings. For the low demand specialties such as primary care and psychiatry, such a statement is incongruous with reality. It should come as no surprise as well that the high demand practices are cash-driven and receive higher CMS payment rates.

Primary Care physicians cannot work the system the same way proceduralists can. A surgeon can do a procedure and bill for that. They will get a fixed rate regardless: X surgery = X payment. PCPs have to jump through endless hoops, with the slightest trip up slashing payment. Thus, we're seeing no shortage of the proceduralists and a dearth of the primary care physicians, precisely for the reasons Dr. Helen laments.

Many PCPs would love to "evolve" into the model you suggest. Unfortunately, the population with the highest need for PCPs are insured by the government. You cannot force the government to change. The entire landscape of practice is changing, and for the worse. Some of your sentiments are correct, but for just one area of medicine. We already ARE running short on doctors, though there is no shortage of medical graduates pursuing top dollar residency.

9:53 PM, June 25, 2008  
Blogger Jamie Irons said...

Richard wrote:

"Another thing. You will find that the future belongs to those doctors who not only are good doctors, but who understand patient service and the business of medicine. Gone the way of the Model-T will be the ones who thought the word "Doctor" before their name was the only requirement to the gravy train. The legal profession has already gone through this evolution, with mostly positive results for clients. Now it's medicine's turn to evolve."

***

In my neck of the woods we went through that sort of evolution twelve to fifteen years ago; we are actually quite good at service and the business of medicine, and no one has been able to duplicate (so far) what we do. We only accept the top 25% of applicants into our practice group, and look them over for three years before letting them in the door.

But what is driving people away from medicine is not a failure to adapt, a failure to take a service orientation, or a failure to understand business and economics.

It is rather the meddling of all sorts of third parties that are imposing restrictions on the practice of medicine that are killing its soul.

You really have to be there to understand it.

It's a "doctor thing."

In Kafka's short story, Der Landartzt, there is a scene where the villagers chant (about the country doctor),

"Und heilt er nicht, so totet ihn...Nur ein Artzt, nur ein Artzt..."

"And if he doesn't heal, then kill him... Only a doctor, only a doctor..."

(I'm relying on memory here, and I can't do the umlaut in Blogger, so forgive me...)

Jamie Irons

10:02 PM, June 25, 2008  
Blogger Dr. M said...

You guys don't understand Mary. In her world, medical policy is handed down on high from the gods. There is nothing that she can do or you can do to change it. Discussing its problems is like questioning the gods. What's the point? Just live with the cards you've been given, and drink wine and drive a sports car.

And like many a battered wife, she honestly believes that the gods in Washington really do love her, despite their "flaws" and "shortcomings".

12:30 AM, June 26, 2008  
Blogger Mary said...

OK--it's your payday, and you have bills in your mailbox. But instead of a check, your "pay" envelope contains an EOB denying half your wages as excessive, and requiring you to submit additional paperwork for the other half, which you may or may not receive in another 30 days. How long would you continue in your job?

Let's see... I think I answered this one, but I would:
1)investigate hiring someone who was more capable at billing.
2)consider creating a joint practice with similar providers to share costs
3)be realistic about govt entitlement programs, the demographic timebomb, and the obvious need for further cuts in the coming years.

I'd realize that whining about reality isn't going to keep those govmint checks coming in, and I'd ask myself how committed I really was to my field and where I could cut expenses.

7:25 AM, June 26, 2008  
Blogger Mary said...

I thought it was telling that they never got back to me with any explanation of how this had happened, or exactly what had happened.

Perhaps they didn't want to advertise how it works. Besides, why should the private non-profits who administer MC serve as your private investigators. They lost enough money on that fraud before it was caught it seems; it's really not their job to report back to you exactly how the fraud was caught and how you were victimized. (entitlement mentality at work again...)

7:29 AM, June 26, 2008  
Blogger Cham said...

I wasn't aware that doctors were obligated to sign up for Medicare, Medicaid and private insurance reimbursements. If you don't like the process then don't do it. With the ever growing number of medical self-payers out there, there has to be a market for a cash-for-services medical practice.

Is it really a doctor thing that nobody else but highly educated and highly paid doctors would understand? I think not. Many people's career paths have changed over the years, think about the guy who was trained to make buggy whips. Are doctors the only people that are completely inflexible?

8:22 AM, June 26, 2008  
Blogger Pogo said...

Ah, Mary, the Althouse troll, over here pissing in a new punchbowl.
Hi Mary!

Best put her nonresponsive comments aside, for they are merely and intentionally insulting and belittling (it appears to be her baseline personality). Buy a red car! Shut up and stop whining! Get used to shit sandwiches, some find them mighty tasty!

The problem is, as one expects, primarily economic.

1. In American medicine, it is price controls that distort the market. These price controls do not affect any other profession, so the usual answers about better management including reenegineering, better software, advertsing, and "lean thinking", will have minimal if any effect. Those are all dependent on a free or mostly-free market, which US health care is not.

2. Price controls, according to Sowell, inescapably cause shortages due to the laws of supply and demand. He writes "People will not supply as much at a lower price as they will at a higher price." and "On the demand side, people will demand more when the price is kept artificially low by price controls."

3. Both quantity and quality decline under price controls. Quantity declines in medicine as visit times get briefer and briefer. 30 minute visits used to be common. Now 5 and 10 minute visits are the norm in family practice. Quality erodes in the form of waiting, delays, refusal of certain services and meds, bureaucratization, and declines in service.

4. In single payer systems, the patient is not the customer, the government payor is. Guess who gets most of the attention? Not you. You say your hip hurts? That's too bad. But we'll deal with that "next time". On this visit we have to document we took care of all the required preventive services, whether you want to or not, because Uncle Sam sez so.

5. Quality also declines because price controls mean your pay is forever capped and is very likely to decline. Bright young people are aware of the warnings about going into a profession whose renumerations are politically determined, and not dependent on service, quality, speed, or efficiency. They instead choose finance, law, accounting, and other fields. (Mary, you didn't think MDs were angels or monks, did you?) Geniuses won't enter medicine and won't discover cures. But they'll make damned fine CEOs and managers.

6. PAs and NPs are great for some things, but the fact is they have less training and are less knowledgeable. Often, they are unaware of their limitations. They are lower quality, but 'good enough for government work'. You get what you pay for, after all.

7. Doctors are stuck. Short of leaving the profession (or country, which seems increasingly an option to me as health tourism ramps up), they have no choice but to suck it up if they stay.
Except they will discover what every other country with medical porice controls has done.
They will go on strike.
And it will increase their pay.
And they'll do this over and over again. It's easy, and it works.

8. Anti-doctor animosity and schadenfreude is understandable.
but this is one case where you'll regeret what you wished for.

9. Price controls have always failed, everywhere they have been tried, going back 40 centuries. But politicians and their patrons, the voters, will always believe you can get something for nothing. So here we go again.

8:28 AM, June 26, 2008  
Blogger Pogo said...

This comment has been removed by the author.

8:41 AM, June 26, 2008  
Blogger Pogo said...

10. Medicine is a commodity, but only at the margins. Some care like minor sore throats, blood pressure rechecks, mild diabetes management, and low back pain assessments can be routinized.

But when your patient is 82 and has an active problem list of 15 items, then you want a practitioner who is an artisan. Someone who will spend the time, examine you, know the research, know the medicines, and has experience and creativity to call upon, and have the time to answer the numerous questions from the daughters and sons.

But say goodbye to all that. When doctors get shit sandwiches, patients get shit sandwiches. Welcome to Medicare! Now get in line and shut the hell up.

Do I got it now, Mary?

8:42 AM, June 26, 2008  
Blogger Mary said...

But when your patient is 82 and has an active problem list of 15 items, then you want a practitioner who is an artisan. Someone who will spend the time, examine you, know the research, know the medicines, and has experience and creativity to call upon, and have the time to answer the numerous questions from the daughters and sons.

Quit yer bitchin'. Plenty of older Americans still get top-quality health care, and their providers aren't so harried about paperwork that they can't answer the questions and communicate with sons and daughters because they are taking on too many cases pro bono and struggling to collect. If you're eating a shit sandwich, stop. Shop around. And be prepared for even more cutbacks, with providers tightening their belts too, because it's a numbers game and the cuts are coming...

Hope this helps, Pogo. Any more questions, feel free to ask. And remember that a negative "woe is me" attitude is rarely healthy; why not think of all those worse off than you who are still able to make a go of it, on much less $$ I suspect.

10:32 AM, June 26, 2008  
Blogger Cham said...

Artisans? You have to be kidding me. If you want an Artisan/Medical Doctor then head over to a top hospital pull out your checkbook and start writing. As a tax payer am I expected to pay for artisans? I've already had it with the whole "No child left behind" where differently abled children who can't even tie their shoe laces because of the lead paint chip ingestion are attempting to being taught to diagram sentences. That isn't going to work but if George Bush tells the educators to do so they have no choice.

Then there is the environment with the water quality drinkable and swimmable directive. It is an impossibility to remove the lead and chrome out of some water supplies but that doesn't stop the feds from demanding that we should be able to drink the Delaware River.

Then there is the issue of the disabled who now have every small business and government agency by the short hairs. The handicapped can legally demand a wheel chair ramp on every front entrance of any business or agency that deals with the public, never mind that many urban buildings were built years ago and there is no way to accommodate a ramp. If you don't comply then out of business you go. Oh, they don't like the back entrance because they feel like second class citizens, so only the front door will do.

Doctors, educators, social workers all feel that the government is a bottomless pit when it comes to money. It isn't, we've already run out and are borrowing on money we will never have. Pay for the transplant, pay for the special teacher, pay for my extra police patrols, pay for the new road. Pay for it yourself.

10:58 AM, June 26, 2008  
Blogger Pogo said...

why not think of all those worse off than you who are still able to make a go of it

Indeed I am. They have done so by shedding Medicare entirely. Which is the way my office will be going. Which is the way many many MDs have gone.

Too bad about the old folks, though.

Plenty of older Americans still get top-quality health care
"Plenty"?
In many towns across the US, the local MDs are reducing their Medicare patient load, and refusing new Medicare patients altogether, forcing the elderly to leave town to find any doctor at all. 'Plenty' is no longer accurate.

11:40 AM, June 26, 2008  
Blogger Pogo said...

Doctors, educators, social workers all feel that the government is a bottomless pit when it comes to money. It isn't, we've already run out and are borrowing on money we will never have.

But I fully agree with you; we have no quarrel at all. Government should get out of these areas entirely. No, I do not "expect" government-paid fees from taxpayers.

I want individuals to pay me what they think I am worth. That is all. But government forbids that, and their price controls are beneath the cost of production and as a result unsustainable.

11:49 AM, June 26, 2008  
Blogger Pogo said...

And Mary, doctors are doing more than bitching, they are moving with their feet.

Away from Medicare. Away from primary care.

From US News:
"• Twenty-nine percent of people with Medicare said they had trouble finding a doctor who would take that insurance in 2007, up from 24 percent the year before. That's 11.6 million people.

• In Texas, 24 counties now have no primary-care doctors at all.

• In Alaska, not one of the 749 private-practice physicians was taking new Medicare patients for primary care in November 2007.

• A typical medical student graduates with $130,000 in debt. As a result, the number of grads choosing residencies in family practice, internal medicine, and pediatrics fell 7 percent from 1995 to 2006.

• And while half of residents in internal medicine chose to go into primary care in 1998, now just 20 percent do."


Goodbye, Medicare!
Goodbye, primary care!
Hello nurse practitioners with 2 years of training!
Good luck, baby boomers turning 65; you'll need it.

11:58 AM, June 26, 2008  
Blogger Joe said...

But when your patient is 82...

It's time to die.

Spending a disproportionate amount of money so a sick 82-year-old will live to be 84 is crazy.

1:26 PM, June 26, 2008  
Blogger Helen said...

Joe,

".. is crazy."

Not if that is your father or grandfather etc. or yourself one day. Also, many people have good quality of life even at older ages. I had an aunt who at 90 could not find a doctor to do heart surgery but finally did and went on to live 4 more happy years.

1:42 PM, June 26, 2008  
Blogger Pogo said...

Actually, the longer you live, the greater your life expectancy, and most often not disabled. (from Harvard:.

If you reach age 65, current life expectancy is age 83.

If you reach age 75, life expectancy is 86.

If you reach age 85, life expectancy is 91.

1:52 PM, June 26, 2008  
Blogger TheNewGuy said...

Those of us in the ER are not looking forward to the 10% pay cut that's coming next week, and other cuts coming down the line. By federal fiat (greatest unfunded mandate in fedgov history), we have to see everybody who walks in the door, insurance, low-payment or no-payment. In my ER, we're 45% 'caid and self-pay (eg. no-pay)... gotta love EMTALA.

We are sometimes surprised to see a patient who actually has insurance. At least you office-based guys have more control over who and what you see. If we opt out (and that presumes our hospital would allow it), we'd be lucky to get paid at all, considering the other insurances who would drop us for not being "Medicare providers," and considering how few of our patients have insurance of ANY kind.

As the demographic bomb starts to impact in the next 5-10 years, I think we're going to see more and more physicians bail from Medicare. Unfortunately, when those older, sicker, complicated patients can't find a doctor, they're going to end up en masse on the doorsteps of hospital ERs, further stressing a system that's already cracking under the load.

BTW, Mary... the irony of a "Medicare financial" bureaucrat lecturing us docs on quality and access to care isn't lost on us... and that imperious, condescending tone? Perfect! Is that a God-given gift, or did you take a class?

2:08 PM, June 26, 2008  
Blogger orthodoc said...

Interesting that "Mary" works in Medicare Financial, whatever that is. I suspect it's the folks who prosecute providers for fraud when a 99223 is coded, rather than a 99222. Important work, no doubt, and thank you for your service to the country.

Let me try to explain this is small words.

If it's not worth someone's time to practice medicine, they won't do it.
If a physician can't pay his office staff, rent, billing overhead, and so on, they will leave the profession.

Suggestions to buy a sports car, drink more wine, and stop complaining are asinine.

Suggestions to get more efficient, hire a billing specialist, form a group practice, and so forth, are similarly asinine. What the hell do you think physicians have done already?

No one in medicine has an entitlement mentality, or the belief that the world owes them a living. What we do think, however, is that shrinking reimbursement should not be combined with ever-increasing demands for uncompensated work, documentation, and arbitrary denials for services rendered. A good example of this is EMR - CMS has basically foisted an expensive and time-consuming requirement onto providers. Unfunded mandate, anyone?

The idea that there is an unlimited supply of new doctors waiting in the wings is fallacious. The most popular areas of residency now are dermatology and plastic surgery. Why? Because both allow patients to pay privately, without bureaucratic interference.

Want a primary care provider? Better get used to self-care, because they aren't in the pipeline. And if they're not training now, they won't be there in 10 years.

Want a specialist? In my city, there is not a single private orthopaedic surgeon who accepts Medicaid. Not one. Remember: If it's not worth someone's time to practice medicine, they won't do it.

3:54 PM, June 26, 2008  
Blogger TheNewGuy said...

Want a specialist? In my city, there is not a single private orthopaedic surgeon who accepts Medicaid. Not one. Remember: If it's not worth someone's time to practice medicine, they won't do it.

You've got that right.

I treat indigent patients in the ER all the time with broken bones ("rolled my 4-wheeler," "fell off my skateboard/trampoline/etc"). We have a tough time getting them followed up, because none of our local ortho guys take Medicaid. The patients go to the office, are asked to pay X-dollars up-front, and they promptly show up back in the ER ('cuz it's free), incensed that they were asked to pay... after all, "I got my Gold (medicaid) card!"

You can't explain to some of these folks that things cost money. I try... I point out that the orthopod has to pay his light bill, his rent, his taxes, his staff, his malpractice, casting supplies, and so forth... and his seeing them isn't "free"... it takes up an appointment slot they could fill with a paying patient. It literally costs the orthopod money out of his pocket to see them!

I then ask them this question: "Would you call a plumber to your house, have him fix your drain, and when he's done, demand 80 bucks from him? Of course not... but that's what you're doing to the orthopedic surgeon."

As Medicare cuts reimbursement back and back and back, it's going to become the new Medicaid. Short of huge tax increases, means-testing, or benefit cuts, there's simply not enough money to sustain the oncoming tsunami of retirees.

I like what I do, and I'd like to keep doing it. I can only hope that by the time it gets that bad, I'll be in a financial position that I can walk away if it becomes too much.

5:45 PM, June 26, 2008  
Blogger Cham said...

TNG:

Forgive me if I point out the obvious, but if the "indigent patients" can't get treatment when they fall off their skateboard or their 4 wheeler or trampoline (or get pock-marked with bullets) perhaps they might be motivated to avoid those situations.

It would be a win-win.

7:43 PM, June 26, 2008  
Blogger Mary said...

want individuals to pay me what they think I am worth. That is all. But government forbids that, and their price controls are beneath the cost of production and as a result unsustainable.

So opt out of the MC system already, set your own rates, select your own patients, and make a competitive go at it.

Just don't spend so much time worrying about all those elderly MC patients who will no longer qualify for your compassionate top-quality care. You won't be missed -- there are plenty of other providers able to work within MC regulations, and balance the paperwork and doctoring demands and still lead a healthy, stress free life.

This article you're all talking about, claiming it's representative of the whole country where nobody'll be able to find/afford a doctor tomorrow, and if they do, they'll get crappy care because all the good ones are tossing in the towel? It was published in the NYT, folks.

Um, since when do you think the NYT is representative of the country as a whole? Nope, sorry don't buy it. Maybe vote with your feet, as the kids say, and find yourself a better area of the country to live and practice in, a better profession that you can compete effectively in, etc. That, my friends, is the old American way. No whining and making bogus threats about how much the system will miss you once you're gone.

8:06 PM, June 26, 2008  
Blogger Mary said...

Hello nurse practitioners with 2 years of training!


What part of the country are you in again? Many nurses I know do a 4-year BA to get the RN, earn a masters, and then later do an additional few years to qualify as a nurse practitioner.

And pssst -- plenty o' those Harvard trained docs don't have the common sense God gave an ant. I suspect they are the ones feeling sorry for themselves that their dreams, hopes and ideals didn't live up to reality, and cut and run when the job became too much. Luckily, not everybody caught the entitlement bug that seems so prevalent in the Ivy League schools these days. (see the NYT for further stories in this vein: "Boo hoo. Live isn't turning out to match my youthful dreams." Boo hoo indeed.

8:11 PM, June 26, 2008  
Blogger Cham said...

Mary:

Don't you get it? If you stay in school for 12 years and acquire a boatload of debt in the process, the gubmit owes you a check and it best not be late with delivery. The whole bootstrap thing is for the little people, not doctors.

8:15 PM, June 26, 2008  
Blogger Mary said...

Suggestions to get more efficient, hire a billing specialist, form a group practice, and so forth, are similarly asinine. What the hell do you think physicians have done already?

See, you can't even read properly. I sure as heck wouldn't trust you to listen to me as a patient when you're so busy worrying about paying your bills, and living within your means.

Helen, whom the suggestions were given to in good faith, said upthread she has done none of the above. Which is why I made the suggestions, in a helpful vein. Light a candle or curse the darkness folks. Your choice. It is what it is. And further cuts necessarily are coming. Maybe try to start weaning yourself from the govt teat now, if you're already having trouble meeting the accompanying paperwork demands and find the compensation to be too low?

8:16 PM, June 26, 2008  
Blogger Mary said...

Thanks cham. Got it.


And isn't it ironic that some of those that have truly been the most blessed in society, with all the opportunities open to them, seen to be some of the saddest sacks around? National sacrifice indeed. We seem -- in some areas -- to have become a nation of whiny wimps, unable to make individual decisions that will benefit them and adapt to changing times.

Maybe they should have gone into a lucrative vocational profession. Something like plumbing or carpentry where they could naturally choose clients, structure their own practices, and not be so dependent on the government taxpayer funds. At 40, it's still not too late to find that field and the independence you're hoping for...

8:20 PM, June 26, 2008  
Blogger Allison said...

--My real point is that by the time you have been in the field for some time, have family responsibilities and understand the realities of the "helping profession" you are now stuck in, you finally realize you may need help yourself.

This is the core issue, and sorry, but it isn't limited to your profession. What IS limited in your profession is that you guys can have gone SO FAR for SO LONG before figuring it out.

It's because of how people go to medical school and residency, living in a kind of la-la-land where they constantly tell themselves the only thing that matters is med school, residency, etc. the rest of us at the same age are already learning about family responsibilities, financial responsibilities, and the realities of their profession. So we have already turned that corner. By mid 30s or later, we've accepted the truths in our professions, learned to negotiate them or change them. We don't feel as stuck because we aren't ruled by the irrational emotional value of our sunk costs the way you are, either.



I have never met a group of people more oblivious to the realities of day to day living than people on the path to their MD and board certifications. They don't seem to bother paying the bills--others do it for them. They don't plan for retirement--others do or no one does. They don't pay attention to what their student loans cost. They don't pay attention to politics, finance, or any thing else the rest of us come into contact with on a daily basis, so when they finally pull their headabove water, they are SHOCKED SHOCKED to see just how unpleasant things are.

What needs to change is the tunnel vision. When that changes, then real changes can be made in the industry. But as long as people begin at 20 to ignore reality until they are 37, it's not surprising they are disappointed with what they find there.

11:12 PM, June 26, 2008  
Blogger TheNewGuy said...

Just don't spend so much time worrying about all those elderly MC patients who will no longer qualify for your compassionate top-quality care. You won't be missed -- there are plenty of other providers able to work within MC regulations, and balance the paperwork and doctoring demands and still lead a healthy, stress free life.

Ahahahahahahahahahh!!! *snort*

Oh, God Mary... don't ever change! That was the greatest unconnected-to-reality, dismissive, bureaucratic-arrogance, there's-no-problem-here-but-you response I think I've ever read!

I'm in tears here... thank you for that... that was great.

And the band played on.

9:20 AM, June 27, 2008  
Blogger Major-General said...

Cham ...attempting to being taught to diagram sentences....

Sorry, the last time I saw a sentence diagramed in a public school was in Latin 2. There were exactly two people in the room out of 30 who could do it: the teacher, and myself. And the only reason I could was the four years spent in private school.

TheNewGuy: Some of us self pay patients would be more inclined to pay if:

1)we had actually been treated, or examined. Not that I minded lying on a gurney in a hall for three hours before being seen. After getting up to walk out. With an almost slipped disk and the most excruciating pain in my life.

2)I could get itemized billing - and not procedure codes. I'm not an insurance company and itemized bills that tell me what was done allow me to assess the value for my money. Particularly after lying on a gurney and getting a separate bill from the hospital.

3)Hospitals and billing offices didn't lie. I don't feel inclined to pay people who lie to me.

All in all, it was a valuable learning experience. After all, I didn't know that three hours in a hospital and not being seen by a doctor while unable to move and in pain is the same cost as five nights in a four star hotel in Austria.

12:47 PM, June 27, 2008  
Blogger TheNewGuy said...

TheNewGuy: Some of us self pay patients would be more inclined to pay if:

I find it curious that you feel entitled to shaft the hospital and physician (neatly shifting your costs onto somebody else), simply because you didn't like your experience. Let me make that experience a little more valuable, since your doctor was probably too busy to explain all of this to you.

Back pain is a common complaint in the ER, and is virtually never fatal (though it's unpleasant, as I know personally). As such, it gets seen after the COPDers, MIs, pneumonias, broken bones, and so forth. The ER is NOT a first-come-first-served place; you're seen in order of acuity. If sicker patients than yourself keep rolling in the ambulance bay doors, then you keep getting pushed back... that's why a cold can take you 6-8 hours to be seen in the ER. Would you prefer I step away from resuscitating a blue infant to get you a pain shot?

As for cryptically-coded billing, there's a reason for that... it's how govt payors and insurers have operated since the late 1970s (when DRGs were first invented). They're great for gathering data and doing cost analysis, but not so much for patients. I'm sure Mary could give you an ICD-9/DRG lecture that would make your head spin.

As for lying, I'm afraid I'd need a few more details on what you're talking about before passing judgment.

Incidentally, if you're upset about not being seen by a "doctor" (was it a PA? An NP?), get ready for more of that. NPs and PAs are cheaper than physicians, and there's pressure to move them into positions that were previously held by doctors. They may not be as well-trained, but they're definitely cheaper (Medicare only pays 85% if you're seen by one)... and you can bet the bean counters looking at the bottom line will eventually find them to be "good enough for govt. work." Mary stated that there are "plenty of other providers," and she's right... but note that she said "providers," and not "doctors."

As for the high cost... being uninsured AND having the ability to pay is the worst position you can possibly occupy. You end up paying the full-bore, non-insurance-rate, billed-charges cost. That cost IS much higher than what your insurance company pays, but that's because of cost-shifting. To make up for the non-payors, and the low-payors, the hospital and physicians are forced to recover that loss somewhere else (eg. from you). If you've got bucks, and no insurance, the hospital will hit you with the whole bill.

But you can feel good about it, because all those non-payors, Medicaid moms, and illegal immigrants you commiserated with in the ER waiting room? You just paid for their care. Under EMTALA, the govt mandated that anyone who shows up, gets care. Period. Full stop. However, they conveniently didn't allocate money for that mandate. They pushed the financial burden of their mandate onto doctors and hospitals, forcing them to make up the money shortfall anywhere they could.

There's no free lunch... the money has to come from somewhere.

That's the reason for your bill.

I hope that helps.

3:15 PM, June 27, 2008  
Blogger Mary said...

Wow. And you really think, thenewguy, that your compassion will be missed in the profession?

Answer me this: do you think someone in self-described excruciating pain, being billed the rate of 4 nights in an Austrian hotel, would prefer to be seen by a trained medical professional, or to sit in the hallway for four hours because "back pain is common in the ER and we're all too well-trained and educated and not being paid enough to care?"

The truth is, a Harvard trained, debt loaded doctor who never even examines the patient or expresses compassion for their position is going to do the patient less good than a caring, honest-to-God medical provider who IS willing to examine the patient, listen to their concerns, and treat them.

You can have all the brains in the world, but if you're not willing to do the job, please do leave the profession. Again, maybe take up plumbing or carpentry which will pay you better, let you select your clients, and you know ... actually accomplish something after working 4 hours. And when people who are happy with your work get the bill, there generally are very few reluctant to pay it.

Not being seen by a doctor, yet being billed top rates ... naturally it's gonna take a little more badgering to collect on that one. You keep trying though, new guy. Something for nothing, with govmint funding, that's your game, eh? Damn regulations and evidentiary paperwork; why doesn't the govmint just cut the check and go on your word that you've performed the services you say you did??? Lol. Remember, if you don't like the health care system in America, there's nothing keeping ya here. Go get treated overseas, or find a blank govt check from another country -- no paperwork necessary; we trust ya, luv! -- if you don't like the system here. Or are you too tethered to that govmint teat??
:-) (It's addictive that something for nothing mentality, I hear)

3:35 PM, June 27, 2008  
Blogger TheNewGuy said...

Answer me this: do you think someone in self-described excruciating pain, being billed the rate of 4 nights in an Austrian hotel, would prefer to be seen by a trained medical professional, or to sit in the hallway for four hours because "back pain is common in the ER and we're all too well-trained and educated and not being paid enough to care?"

That is great stuff, Mary!

I want you to stick around. I really do... because you're making my point for me. You could have quoted me accurately or honestly, you could have addressed my points, but you didn't even try (and don't think I'm the only one who noticed). You've deliberately misquoted, misstated, and miscasted every one of your opponents in this thread... you don't seem to hear a single thing that anyone has said... it's 100% Mary-on-message, 100% you-doctors-are-the-problem, 100% of the time.

It's absolutely contrived... and very well done. I personally think you're a brilliant troll... a rare, iridescent bird. You've perfectly encapsulated the impersonal, arrogant, dismissive, not-my-job, not-my-problem, not-our-policy, we-can't-do-that, bureaucratic attitude. You're playing it with such perfection that you must have had experience in the field.

I'm tickled to death... because like everyone else here, I've met you so many times before. At the DMV, at the IRS, at CMS, in TriCare. The portrayal is perfect, because YOU are why people hate dealing with the government. Your job is secure, your nest is feathered, you can't be fired, and everyone else is just a number... an amusing, sputtering, frustrated voice on the other end of your phone. You could care less about them, because your paycheck always comes, every two weeks.

All the world's a stage, Mary... never forget that.

4:04 PM, June 27, 2008  
Blogger Cham said...

It's funny how when I go to my veterinarian I always have a consult about what things cost before services are provided and then get any itemized bill that is very explicit. It's service with a smile over there.

I've spent more than my share of time over at the pet hospital for emergencies and I have never had to wait more than 45 minutes even at 3AM with a full waiting room.

How come veterinarians are so organized, kind, compassionate and caring when human doctors aren't? I don't mind passing a credit card over at the vets, and I know my vet is making money hand over fist. They are worth every dime and I am more than happy to give them my money. I never understand how those vets manage to keep all their records on the computer, like every single other business on the planet, and human doctors are still pushing paper.

I think we are at a point where the self-payers are about to revolutionize medicine (for themselves) and everyone else is going to be stuck with the old system filled with arrogant whining doctors. A couple of years down the road we may have a completely different picture of medicine and it can't come too soon.

7:20 PM, June 27, 2008  
Blogger TheNewGuy said...

I think we are at a point where the self-payers are about to revolutionize medicine (for themselves) and everyone else is going to be stuck with the old system filled with arrogant whining doctors. A couple of years down the road we may have a completely different picture of medicine and it can't come too soon.

God bless you, Sir. If I could kiss your feet through this keyboard, I would.

What you're describing is what we USED to have; fee-for-service. You pay for what you get. No middle-men, no hidden costs, no insurance distortion, no cost-shifting, no BS.

My wife and I did that with our children. We made arrangements with an OB/GYN ahead of time, for a discounted pre-set price, and paid cash up-front. It completely cut out the insurance people, and it was just us, and our OB... it was absolutely marvelous. I encourage others to do the same. Talk to your doc about it, and be prepared to pay out-of-pocket. If you're in a non-emergency situation, you have the luxury of shopping around, and finding exactly what you want. I've done it, and it's a nice alternative for elective stuff.

That said, what I do (Emergency care) is a little different. There's no way I'd force a patient to run their credit card before I'd agree to treat their life-threatening emergency... that's flat-out unethical. Think about it... what patient would refuse my price (any price), when he's having an Acute MI, or literally taking his last breath? I'm a doctor, not an extortionist. I have no problem rendering the care first, and getting paid after-the-fact. I just wish more patients (and payors) would hold up their end of that bargain.

10:12 PM, June 27, 2008  
Blogger Mary said...

you don't seem to hear a single thing that anyone has said

Lol. I like that you're learning from me, boy. You didn't listen to the details of the story presented (the patient never got seen in the ER for 4 hours, yet you berated him for not being willing to pay the exorbitant price for such non-care, because the physicians have bills too and shouldn't get stiffed for their lack of performance in even SEEING the patient! *whine*

Then, when called on it, you again turn your comments into a personal discussion of me -- attacking the honest observer.

Hmmm.... now exactly what motivation might you have to keep helen's thread count going, upping the numbers?

ps. Ironic isn't it, that such and overworked and underpaid ER scrub such as yourself has so much time to monitor helen's blogthread.

Lol.

Remember now: if you want "fee-for service", the pay to play old way of medicine, all you've got to do is opt-out of the MC program.

Then you can set your own rates, see your own patients, and compete honestly and effectively in the marketplace without all the whining. Unless you like traeting all the indigent and illegal immigrant patients who come into your ER.

Heck if you get yourself off the teat and have to compete honestly like so many doctors with successful business practices, you might actually find yourself with a better client base willing/able to pay for your services. Assuming of course, you actually examine, listen to and treat the patient. Yes you can!

5:45 AM, June 28, 2008  
Blogger Mary said...

ps. I don't actually carry health insurance myself. Preferring to pay the (inflated) out of pocket costs when/if there is something I need a doctor's professional advice on.

And for the record, I don't go into ER rooms or shoddy hospitals for "treatment". More likely to end up sicker than when you came in, from what I hear...

Preventative care, and paying for yourself. Not subsidizing those who abuse insurance plans, and all the doctors who think they are somehow "entitled" to high pay working for the lower class, often illegal, citizens. Don't blame us if you chose a position better suited to those with personal motivations (Catholic hospitals, say) than trying to make a quick buck. Cuz I don't think you're going to get rich treating (or not treating :) poor people in the ER. (Or that "built in" client base referred by public resouces.) And it really doesn't take much of a financial genius to see that. T

Though I can see where you'd fall for thinking you could just charge the govmint whatever for those services, and tap those guaranteed taxpayer pockets. Thankfully, we have safeguards against that -- imagine how much even more bloated the govmint programs would be without!

5:54 AM, June 28, 2008  
Blogger TheNewGuy said...

Lol. I like that you're learning from me, boy. You didn't listen to the details of the story presented

You mean the poster whose points I addressed in perfect succession? No Mary... I'm not learning from you... I've been doing this long enough, and I've encountered you enough times that you have nothing you could teach me about health care financing, or delivery. Some of the other posters, however, may be learning something by watching you... and therein lies your true value.

I love you... this is utterly priceless.

"lol" indeed.

7:00 AM, June 28, 2008  
Blogger Ronald said...

Newguy:
As a hospitalist, I gave up private practice because of people like Mary. Your comments are dead on and it really is delightful to see the self parody that Mary has become. And no Mary, I am not a Harvard trained whiner, just someone who has read Ayn Rand and hears the siren call of 'who is John Gault'. Our labor is our own, and we are tired of others pricing it. Imagine your salary if we got to choose what you are paid. Then shiver and thank god that you are protected.

1:10 PM, June 28, 2008  
Blogger br549 said...

Honestly, outside of Breyer's vanilla bean speck ice cream, what is worth the price paid by the one whose pocket the money comes from - if compared against ones earnings?
An automobile? Nope.
New or existing home? No, no, no.
Free advice? Well, no one really has high hopes for free advice, do they?
Government? Ha ha ha ha ha!!

2:10 PM, June 28, 2008  
Blogger br549 said...

I have been raked over the coals because I am not indigent. I speak of "the new guy's" post of 3:15 P.M. on June 27. I can vouch for what that post says.

The sad part about that, is it smacks of "from each his ability, to each his needs".

Insurance will not pay those rates. Indigent folks can't. Most bankruptcies are over medical costs, if I am not mistaken. And I know from personal experience that there is no one quicker on the draw and more willing to destroy you financially than a for profit medical establishment.

I have been unlucky in health over the last few years - my ex first, then my own problems came along. I have paid cash out of pocket equal to a four bedroom home, depleting all savings and investments, and I still face an insuperable mountain of medical bills. I couldn't borrow a nickel if I used a dime for collateral. While the miracles of modern health care have saved my life, the costs have also ruined my life. If I never get sick again (too late, I am) I will be paying medical bills until I die. And I get hounded daily. DAILY.

National health care is not the answer. Capping costs and fees is scary, if it caps available science, treatment, heroics, etc. And driving the best there is out of the "industry" will only serve to halt the population boom and social security problems looming on the horizon. Plus, what the hell else do doctors know how to do but save lives? I wouldn't want a neurosurgeon to paint my house, design a four lane bridge spanning a river, or put a new mass air flow sensor in my Nissan Maxima (or be the one to diagnose that's what is actually needed).

Don't get sick, ever. Don't get hurt, ever. That's the only answer I have been able to come up with.

And who is at fault? Every single, solitary snowflake in this avalanche. And if we really want to screw things up, let the government fix it.

I hate it when there is no answer.

9:39 AM, June 29, 2008  
Blogger Ronald said...

BR549:
I am sorry to hear of your illness and hope that all goes well. You are right about the snowflake/avalanche analogy. The doctor-patient relationship is now the employer/insurer relationship with the the MD-patient left in the dust of bean counters. It's absolute craziness that the top medical minds of Mayo/Duke/UCSF get essentially the same reimbursemnet at "last in class, no where else to practice" physicians. But as Bill Engvall puts it "there you go"....

10:59 AM, June 29, 2008  
Blogger Mary said...

And no Mary, I am not a Harvard trained whiner, just someone who has read Ayn Rand and hears the siren call of 'who is John Gault'. Our labor is our own, and we are tired of others pricing it.

So opt out already and set your own rates.
Yes you can!
Join the thousands of other providers who have had the courage to stop whining, and grab this bit of independence for themselves.

Honestly, you people want someone to hold your hand for you...

5:55 AM, July 01, 2008  
Blogger Mary said...

and br, did you ever think of perhaps visiting a financial advisor? Sounds like you're not doing too successful managing your money on your own. Surely they can help.

5:56 AM, July 01, 2008  
Blogger br549 said...

I'll go see a financial advisor if you'll go see a psychiatrist, mary.

To paraphrase Churchill, I am broke, but you ma'am, are crazy. But tomorrow, I will no longer be broke.

Your blog rep precedes you. So I am laughing AT you, not with you. I suspect we will now go a few rounds again, until you lose, as usual, and disappear for a few months, as usual - only to return, as usual, to lay your crap on the next round of relative newbies.

There is a pattern. I guess your quarterly round of free med samples from the doctor ran out, and you again get on the net.

I gleefully await your reply, as I know you just can't resist.

6:56 AM, July 01, 2008  
Blogger Mary said...

Oh br...

Some of us have, you know, lives. But if you really enjoy "sparring" with me so much...

I think your problem, personally, is that you think "meds" can solve anyone's problems in life. Me? I think people work hard, think hard, and resist victimization. Hence my continued repeating of tips to take control and opt out of MC if you are an unhappy provider... But then again, if some of you here weren't unhappy victims, you wouldn't know who you were...

Lol@ my "rep precedes me". I'm flattered, really. You must not get out a lot though, if you think I'm unique in questioning some of the bogus threads and ill-formed conclusions online. Are you homebound, by chance?

6:49 PM, July 02, 2008  
Blogger serket said...

I am coming to this discussion late, so I probably won't get a response. I feel sympathetic to the doctors in here. If something bad happens to me, then I want a doctor.

I currently do not have insurance, because I just started a new job. While it can be relatively expensive I think it is nice. Although perhaps something that only covered emergencies would be better. From a patients' perspective using insurance is great, because the company can ask for lower rates. Of course this is frustrating to the doctors. Do most of you think that insurance is acceptable, you just can't stand the government sponsored insurance of Medicare and Medicaid and the various state versions?

I definitely support tort reform, we need a cap on the amount that can be won in a lawsuit and perhaps a loser pays policy.

9:49 PM, August 02, 2008  
Blogger BigBadErik said...

Hey Folks,

I'm not a doctor, but my mother is, and I worked in her office supporting her over holidays during high school and college...and I have lots of firsthand knowledge of what a doctor goes through during her day-to-day office hours.

One day in high school, Mom told me that if I went downtown and took a one-day course in Medicaid billing, I could do all Mom's paperwork myself and KEEP EVERYTHING I billed Medicaid.

I took the course, sat down, and started work. Two days later, I told Mom that it was not worth my time. A high school student. One who is usually paid minimum wage, no matter how smart, organized, or driven. Said it was not worth my time. I took a job working construction for eight dollars an hour and was happy for the experience.

This was 1986. Twenty-two years later, the situation has become even worse for doctors. The paperwork, the insurance chokehold on the industry, the malpractice insurance, the rent, the city/state/federal regulations that cost doctors thousands of dollars annually, the sharps containers, and so on...make it prohibitive for any doctor to practice medicine IF she wants to do a good job for her patients.

Sure...if a doctor wants to run a patient mill...in and out of the office in fifteen minutes with shoddy medical care...she can make enough money to survive comfortably. But this is NOT the way a conscientious doctor runs a private practice.

This year, Mom joined a medical group and is extremely happy to be on salary.

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Blogger nurs4lyf said...

In regards to the story that you posted several months ago. It appears that we are on the brink of actually passing some healthcare reforms, I can see the insurance companies bracing for the change. As a nurse I have watched my patients frustrations mount repeatedly over insurance issues. These issues range from costs of prescription medications, coverage limitations, preexisting conditions, and simply being dropped from after becoming ill. Not to mention the cost of coverage. As a health professional face the same dilemas. Even though our employer usually owns our insurance companies, we are still victimized by high insurance costs, high co-pays, treatment limitations and preexisting conditions. I continue to see the need for healthcare reform along some extensive renovations to our insurance and pharmaceutical industries

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