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Sneaky Things That Doctors Do To Survive Financially – Introduction

Dr. Val’s note: My friend and co-blogger Alan Dappen is going to prepare a series of posts to expose the convoluted billing and procedural tactics that primary care physicians adopt to survive the ever decreasing reimbursements that would otherwise put them out of business. Below is his introductory post – others will follow each Wednesday morning here at Better Health. Enjoy!

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The Doctor’s Huddle

By Alan Dappen, M.D.

On the great gridiron of healthcare, the team of primary care providers is leaning inward, supportively embracing one another.  They have huddled together for 15 years, calling plays against their opponent, the Insurance Team.  The two-minute warning has sounded and the Physician Team is losing. The Physician’s play book pieces together strategies culled from cocktail party conversations, doctor conventions, office staff meetings, back hallways of hospitals, online blogs, and a plethora of practice management magazines; routinely circulated offering grand strategies to teaching doctors how to tackle the Insurance Team. The rising mantra is “Hit them again! Harder! HARDER!”

This game began in the 1980s, when concerns that rapidly inflating healthcare costs would consume all the U.S. gross national product within the foreseeable future unless something was done.  Insurance companies lobbied regulators and advertised to the public not to socialize healthcare. Most people sighed relief when laws were passed granting insurance companies broad powers to regulate the price of care.  Little did these politicians realize that they inadvertently were “socializing” care by handing the keys to the health care gold mine to Team Insurance’s privatized, for-profit model.

Up until this point, the healthcare system had experienced 40 years of run-away costs. Patients with insurance hadn’t worried about the costs of care. Inside of this cash rich environment, many important innovations occurred but employers, who subsidized most of the cost, questioned the sustainability of paying for it.  All the while, physicians, hospitals, pharmaceutical companies, and medical suppliers eagerly reassured the patients:  “Since you aren’t worried about the price, then no one else should worry about it either. We’ll pass the bill to the insurance company–they pay what we ask.”

This modus operandi came to a screeching halt in the late ‘80s, when the aforementioned game began, and Team Insurance was allowed to fix prices via preferred provider contracts. Insurance providers understood that the key to these contracts was not to change the rules for patients, who needed to perceive their care as virtually free so that they would continue to seek care.

Instead, Team Insurance spelled out new game rules in contracts for physicians, where the physicians “negotiated” to accept roughly 50% of their customary rate in order to be listed in the insurance company’s Preferred Provider Directories. These rules were never acceptable to physicians. Docs refusing to sign contracts rudely were awakened by the new world order when 95% of their trusted clients refused to return until they could say, “Yes we are preferred providers.” And, “Yes, all you have to pay us is your co-pay.”

Patient expectations remained unchanged. Quality of service, patience, time to explain oneself, attention to wellness, review of multiple issues, meaningful personal relationships, prescriptions, detailed explanations of risks and benefits of treatments, reviews of other possible ideas in a differential diagnosis,  labs, call backs with results, and introductions to specialists were never connected to a price for patients before. After all, haven’t physicians had spent 40 years reassuring patients, “Don’t worry your silly little head about the price.” This time the boomerang came right back at physicians who suddenly were demanded to deliver all the same service for half the price.

The power of “owning” the patient for a $20 co-pay is not lost upon the insurance team.  Every year, as they hand out new contracts, these insurance companies congratulate their preferred doctor players for their work, quality, and dedication and try to not rub in the following truth, “We own the doctor and we own the patient. Any doctor who dares not sign our next annual contract for less money will find themselves without patients. Remember, for the patient the big thing that counts is that you can say yes to the $20.00 co pay. Now sign on the dotted line.”

Every “negotiated” dollar saved from paying Team Physician means smiles all around for Team Insurance and their fans (shareholders.)  Price fixing initially did control costs, but only for about five years.  The U.S. now is back on the trajectory of health care pricing doubling every 7-10 years.

So what’s going on in those primary care huddles? The game plays are called out: “More work, less money, patient demands, protection from malpractice, keep smiling … Somehow we’re going to make somebody cough up our money …Hit them again harder!  Let’s do it!  On one, break.”

Up next, I’ll show you some of the plays physicians have put into place to survive. And why you the patient might feel like the football. Play along, with us. Hup one, Hup two, hike!

Until next time, I remain yours in primary care,

Alan Dappen, M.D.

Parents need to know about vaccine safety

By Stacy Beller Stryer, M.D.

After my blog last week discussing the recent increase in Haemophilus influenzae B (Hib) cases in Minnesota, I received a comment from “Indian Cowboy,” who is a blogger and fourth year medical student. While Indian Cowboy admits that he isn’t completely against vaccines, he does question their safety and says that, “if my (future) patients were to ask me specifically, scientifically, what the risks of vaccines are, I would be forced to shrug my shoulders and say I actually have no idea.” He suggests that pediatricians, in general, are not open and honest with their patients about any side-effects associated with vaccines. Furthermore, Indian Cowboy comments that he is a member of the “current generation of medical students,” where evidence-based medicine is important. Does this mean that we old-timers (yes, I am an ancient 45 years old), don’t practice medicine based on results of quality studies and proof of what actually works?

 

That is far from the truth. My colleagues and I practice medicine based on what has been proven to work and not just what we learned on a whim. We continue to read reputable journal articles and other medical literature, often discussing treatment changes based on new research. And I do not know any pediatrician who makes a blanket statement that vaccines are 100% safe. Personally, I spend a fair bit of time talking to parents who question vaccine safety. I tell them that anybody can have a reaction to a vaccine, just like anybody can react to an antibiotic, food, or something in the environment. I also discuss more common side effects of vaccines, such as fever, redness, and irritation at the injection site. In addition, I mention that there are very rare, more serious side effects associated with some vaccines, such as seizures and encephalitis. I am certainly not the only honest pediatrician in the United States. In fact, reputable organizations such as the Centers for Disease Control (CDC), which are major advocates for vaccines, clearly state on their website that no vaccine is 100% safe or effective.

 

Just as importantly, and an absolute necessity is discussing that the risk of becoming seriously ill or dying secondary to a vaccine is much lower than the risk of developing a serious illness or dying if a child becomes ill with one of the infections for which they could have been vaccinated. Parents must be aware of the benefits of receiving these vaccines. And they should know that vaccines are one of the greatest medical discoveries of the 20th century and have increased life expectancy and quality of life significantly.

 

Back to Indian Cowboy – he also comments that we really don’t know much about vaccine safety because studies only last days or, at most, a couple of weeks. This is also far from the truth. Before a vaccine is licensed, the Federal Drug Administration (FDA) requires testing. Once the vaccine is being used, the CDC and FDA look for any problems and investigate them through the Vaccine Adverse Event Reporting System. It’s true that this system depends on pediatricians and parents to report side effects. This was recognized as a problem, so in 1986 a National Childhood Vaccine Injury Act was developed which, among other things, required experts to intensively review any possible adverse effects of vaccines. In 1990 the Vaccine Safety Datalink project was developed, where researchers gained access to the medical records of over 5.5 million people to evaluate for common and rare side effects associated with vaccines. All of these different safety methods have led to changes in vaccines to make them safer. In 2000, children began to receive the inactive polio instead of the live polio vaccine due to the rare risk of developing polio from the oral vaccine. More recently, the pertussis vaccine was changed from a whole cell to an acellular one because of the increased risk of rare neurological side effects.

 

I could continue, but the bottom line is that immunizations have been tested extensively for safety and continue to be monitored by reputable, quality organizations. There is an abundance of information available on safety for every vaccine. It is true that we cannot assure parents that their child will not develop a severe allergic reaction or a rare side effect to a vaccine. And we cannot say that we are 100% sure that vaccines do not affect the brain or the immune system, such as we cannot assure them that they will not get into an accident when they step into a car or that they will not be hit by a car when they cross a street. But we can reassure them that the chances of such an event are rare and that the benefit of receiving the vaccine far outweighs the risk of not receiving it.

 

I certainly hope that the one case of epiglottitis and pertussis that Indian Cowboy saw last year makes him realize not only how serious these infections can be in infants and children, but also that he only saw one case of each whereas, without immunizations, he would have seen many more and, most likely, a few deaths.

 

When Your iPhone Finishes Your Sentences

I personally find the word-completion tool kind of annoying on the iPhone – especially as a doc. The software is geared towards choosing the most common word after a few letters, and you can bet that physicians are not typing out common words. Like “emycin” is not “empty” – I’m just sayin’.

A couple of awkward ones recently – my friend was texting me about a tragic and unexpected event and I responded with “Geeze!” which (as I pressed send) turned into “Geese!” That one was hard to explain, and quite insensitive at the time. Err…

Another friend of mine was dealing with a sick kitty at home. She had taken the cat to the vet because she’d stopped eating/going to the litter box. The kitty was diagnosed with an infection and was on the road to recovery, when a couple days later she had her first bowel movement. So my friend decided to text her husband the good news via her iPhone. She typed “the cat went poo,” but alas, the iPhone had the last word. Her husband received this alarming, if not perplexing text message:

“the cat went pop”

Have you had similar iPhone drama? Do share…

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