Something touched a nerve yesterday. I kind of lost my composure when someone tried to defend the insurance industry and responded out of emotion – perhaps putting aside some reason in the process.
I used to get mad at myself or embarrassed when this happened, but now I stand back and try to analyze my reaction. What is it that touched a nerve in me? Why did I feel so strongly? We don’t feel things without reason, and my reaction doesn’t necessarily betray weakness on my part, it shows the depths of my emotion. That passion usually comes from something – most of the time it is personal experience; and my personal experience says that insurance companies are causing my patients harm. That makes me angry.
I don’t think the people in the insurance industry are bad people. I think vilifying people is the easy way out. The people there feel like they are doing the right thing, and are no less moral than me. But I do not think the way to fix our system is through letting them do their business as usual in the name of “free market.” Defending the current system of insurance ignores some obvious problems in our system:
1. They are financially motivated to withhold services
If you hire a contractor to work on your house, how wise is it to pay them 100% in advance? You have just given them financial incentive to do as little work as possible, as it will maximize their profits to do so. The insurance industry is in such a situation; despite any good intention, they are put in a position to decide between profits and level of service. It is much better to pay more for better service, not worse; but that is what we have done with health insurance companies.
2. They have been given the ability to withhold services
If all United Health Care (for example) did was to provide insurance, they would not be vilified as they are. But since the only data available for medical care was the claims data they hold, they were put in a position to control cost. This was sensible initially, as they had both the data and the means (denying unnecessary care) of cutting cost. It’s OK that women aren’t kept in the hospital for a week after having a baby. It’s OK that I can’t prescribe expensive brand-name drugs when there is a reasonable generic alternative. There was a whole lot of fat to cut, and they did a good job cutting that fat.
The problem came when all the fat was gone and they were used to big profit-margins. Once there was not any more unnecessary care to cut, they had two ways to keep their profit-margins: increasing premiums or cutting services. They did both. Both of these have hurt my patients.
Patients have had premiums increased or have been dropped because they were diagnosed with medical problems. I have had patients beg me “don’t put that in my record,” as they know a diagnosis of diabetes or heart disease will be disastrous. I am then caught between the pleas of my patients and the demands of honestly practicing and documenting my care.
I do what I can to follow evidence-based standards, but there are times when people fall out of the norms. Medicine is not science, it is applied science. This means that I am trying to take an individual and somehow match them with the scientific data. Sometimes it works, but everyone is different. If something is true 90% of the time, 10% of the people will be exceptions to the rule. I have repeatedly been told by “gnomes” (people with minimal medical education who sit in front of a computer screen with a protocol for care) what “good medicine” looks like. They see things as black and white when it is just not that way. This has caused people to be unnecessarily hospitalized, it has required them to get unnecessary tests to follow their rules. There is no arguing with people in front of computers.
3. They covertly ration
Dr. Rich Fogoros (whom I recently met) has coined this phrase to explain what happens in our system. Because it doesn’t look good to deny necessary care, insurance companies (including government-run ones) resort to making things exceedingly complex. This makes it look like care is being offered, but not taken advantage of. What does this mean?
The burden of proof is put on the provider to show the tests ordered are necessary. The assumption is that a test will be denied unless the doc can prove otherwise.
Tests are sometimes inappropriately denied. They then can be appealed, but the appeal process is even more difficult than the initial approval process, and so some people give up. Every time someone gives up, less is paid out by the insurance company and their profits go up.
The rules for coding and billing are so complex, that it is very easy to make mistakes. This means that an appropriate test ordered by a doctor that is not perfectly coded doesn’t get paid for. The patient gets the bill and must get the doctor to appeal the denial. This appeal process, again, is difficult.
Because of this, I have to hire staff whose sole task is to learn all of the rules of the different insurance carriers (including public ones) and then play the game properly with them so that we get as few denials as possible. I probably spend $70-80 thousand per year to deal with the frustratingly complex system we have.
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I have health insurance. I do understand why it needs to exist, but I also see how harmful the current state can be to my patients. I get frustrated with Medicare and Medicaid as well, but that is not my point. Just because government run insurance has problems doesn’t do anything to change the problems with private insurance. The fact that you can be killed by firing squad doesn’t make the gallows any better.
The cost of care has gone up dramatically over the past 10 years while my reimbursement has dropped. Where is that extra money?
But the system is very broken right now. It needs to be fixed. Things need to be changed in both the private and public sector. When I was in DC I made the point that our ship is sinking and we are arguing about who will be the captain. The problems in our system are not simply who is writing the checks.
Honestly, I don’t really care who writes the checks. All I want is for the system to reward good care and to stop hurting my patients. Those who deny the reality of either of these problems will invariably draw my ire.
One of the storylines in the health reform debate is how the Medicare population is fighting the current reform efforts.
It’s ironic, in a way, since if the status quo continues, fiscally sustaining current Medicare benefits will be a near-impossibility.
In his regular column, The New York Times’ Ross Douthat provides some insight as to the mindset of the Medicare recipient. He says, rightly, that, “At present, Medicare gives its recipients all the benefits of socialized medicine, with few of the drawbacks. Once you hit 65, the system pays and pays, without regard for efficiency or cost-effectiveness.”
When reformers talk about savings, it “sound[s] a lot like ‘cuts’” to the elderly, and hence, their apprehension. Arguments that many of the tests and treatments can be reduced without sacrificing quality of care will not resonate. With the prevailing mentality equating better care with more care, any attempt to introduce serious cost-saving measures will meet a determined resistance from the American public.
*This blog post was originally published at KevinMD.com*
I was glad to see that my recent interview with Tommy Thompson was referenced by Larry King in his opening remarks on healthcare reform with Elizabeth Edwards. My friend Eric Kuhn at CNN kindly offered me the video to embed here on my blog… The Better Health reference is at minute 1:08. I was also asked to submit a blog post to Larry King’s blog, so stay tuned for that! As I have always maintained – medblogs are upstream of mainstream!
AHIP, the trade group representing the nation’s health insurers, released a study decrying excessive physician charges. There’s some amazing stuff in there: office visits being billed at $6200, a lap chole being billed at $9,000 (just for the physician’s portion). Truly egregious, if true — and that’s the qualifier.
The methodology of this “survey” is not really honest. They cherry-picked an insurance database looking for the highest billed charges for various CPT codes. Supposedly they “excluded high charge outliers that may reflect billing or coding errors.” Really? How on earth, one wonders, could they have concluded that an office visit billed at 5,000% the medicare rate was not an error? Were there more outrageous charges that were excluded? Sounds fishy.
Moreover, the survey is promoted as exposing the outrageous fees that doctors charge, when in no way are these fees representative of physician fees. Physician fees, as any other group of data points, fall into a more-or-less normal distribution. There’s a median point around which most practices cluster, and the further out you get the fewer physicians that are charging those fees, high or low. The cited fees are certainly in the 3+ standard deviation tail of this graph, but you wouldn’t know it from the AHIP press release.
They present these outrageous charges as if they are accurate and as if they represented a widespread abuse of consumers by greedy doctors.
The annoying thing about this is that there is a valid argument to be made that the uninsured do face higher fees than the insured. This is of course more of a factor with the much-higher hospital costs, but physician fees are also higher for the uninsured. The reason for this is that insurers demand a discount off the standard fee in order to contract with physicians. This gives physicians an incentive to crank up their fee schedule as high as they can get away with.
So if UnitedHealth comes to me and offers to pay me 75% of billed charges (I wish!), I need to make sure that my fee schedule puts that figure at a level that is going to return a reasonable per-patient compensation. This is less of an issue nowadays, since most insurers prefer to settle on a conversion factor and contract by the RVU, or as a percentage of the standard medicare rates (110-150% most commonly). That’s easier for their billing systems to manage. So there is less incentive for us to keep charges high. But still, a few insurance plans like to do the old way, and there are occasional patients who are insured but we don’t have a contract with their insurer. In those cases, we expect compensation in full, and the insurer usually pays some arbitrary sum that they feel is reasonable, with the patient responsible for the balance.
Does this screw the folks without insurance? Yes, to a degree. Most of the uninsured don’t pay a dime. They just throw out the doctor’s bill, along with the much-bigger hospital bill, and we wind up writing it off as bad debt. Most hospitals, and our practice, will also write it off as charity if the patient asks for it and can show some hardship. So the uninsured will get a huge bill, but they very very rarely have to pay a huge bill.
The ultimate solution for this “problem” of the uninsured being “overcharged” is not, as AHIP implies, to somehow regulate physician charges, but to eliminate the uninsured. Get everybody covered under some sort of insurance plan, and this problem goes away.
*This blog post was originally published at Movin' Meat*
Boy if that statement doesn’t hit the nail on the head.
Talking to Cortese this week, I heard two themes that cut to the heart of the debate. First, he thinks Obama has made a mistake in moving toward the narrower goal of “health insurance reform” when what the country truly needs is health system reform. Imposing a mandate for universal insurance will only make things worse if we don’t change the process so that it becomes more efficient and less costly. The system we have is gradually bankrupting the country; expanding that system without changing the internal dynamics is folly.
Let me give you the truth of our current reality. We as a nation are headed for a devastating bankruptcy at the hands of our current health insurance model. A model that pays for everything (of substance) and passes on those costs to current and future generations.
Obama’s push for health insurance reform will do nothing to save America’s model that pays for everything (of substance) and passes on those costs to current and future generations.
The argument, as I see it, is not that a lack of insurance is bankrupting our country, but rather the model of insurance itself. Getting more of the same won’t make health care less expensive, it will make it more expensive. And ultimately, if we keep paying for things the way we pay for things now, there won’t be any money left for anyone.
Some people argue that spending money now with universal access will create a healthier and cheaper to insure America. To that, all I have to say is look to the history of the last 50 years. Medicare did not make health care cheaper. It has, for the last 50 years lead to a devastating economic death spiral. FREE=MORE is bankrupting our country. The model of insurance is bankrupting our country. The storm on the horizon will be the death of America, unless something changes, and soon.
I think the whole current nonsense debate is a travesty both from the Republicans and the Democrats. Opponents and proponents are both focusing on the wrong issues at hand. The issue is cost. If you can’t control costs, nothing else matters.
Doctors every where should embrace a system of delivery that encourages value and quality. The ones that will fight you tooth and nail are the ones that are ripping off America with their pretend care. The bad ones will suffer as will.
The physicians most expensive procedure is the pen. If doctors can’t lead the way toward cost effective care, then they should get out of the way while others do. Because if we as physicians don’t do something, we will have spent all the Treasury’s money for all future generations. And we will have no one to blame but ourselves.
Thanks again to Are You A Doctor for pointing me to this article.
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