Comments on: Good Conscience is Bad Business

By: Nicholas Fogelson, MD

Nicholas Fogelson, MD — Fri, 19 Feb 2010 01:13:14 +0000

Your post is sad but true. I don't think its only for PCPs though. As an OB/GYN I am sort of a hybrid of PCP and specialist. We do OK on medicaid OB, in fact better than with some private insurers, but it is still very little compared to the time involved. In most states OBs need to deliver about a 100 babies a year to generate the income required to pay for the insurance that would allow one to do those deliveries. Only after 100 babies a year does an OB actually make any take home pay from the choice to provide obstetrical care.

At present I am in an academic setting, but if I were in private practice in the future I would certainly consider a non-insurance model. A GYN doing this could actually provide services that were much more economical than a participating physician. Participating physicians usually bill $250-$300 for an annual exam to insurance, but only get paid $75 or so. If a patient has insurance that does not cover annual exams, which is often the case if they have a non-HMO plan, they get charged the $300 for a visit and as much as $400 for the lab fees. Ultimately they pay way more _because_ they have insurance, which is completely BS. As a physician I don't like it either, but compliance rules prevents us from providing a lower rate to people who have bad insurance. A cash pay system would allow a GYN to charge a reasonable amount, say $125, for an annual visit, and maybe another $50 for the pap. The GYN could negotiate a rate with the lab to do all his/her paps for $40-$45 and end up making a few bucks on that as well. Physician would get paid a reasonable fee, the patient would pay less, and practice overhead would fall Both parties win. The only party that loses is the insurance company.

By: Dr. Rob

Dr. Rob — Thu, 18 Feb 2010 18:43:35 +0000

I agree with you both. In some ways I fight that greedy impulse to go where the money is. But I do resent the fact that there are some contributing very little to the overall health of people who profit immensely (some who actually negatively impact their health), while PCP's, who have a huge impact, end up having to “do what's right” against their own best interests. If we are going to keep a capitalistic system, then at least motivate good behavior with more money. Pay most for what will help the system the most. If there was a way for docs to fix their fees and post them up front, then people could decide on their doctor based on quality, service, and cost. That's exactly what we do for everything else, isn't it?

By: Marie

Marie — Thu, 18 Feb 2010 07:44:07 +0000

Woody, I think the answer is uniquely American.

Anything that has even a whiff of socialism is an anathema. And despite the fact those systems work (albeit not perfectly, I know), they are not going to be put into effect here.

Our system will continue to suck, greed rather than health care will continue to be the driver.

Another uniquely American trait? We want to have our cake and eat it too.

By: Edward Pullen

Edward Pullen — Tue, 16 Feb 2010 10:12:12 +0000

Sad but true.

By: woody

woody — Tue, 16 Feb 2010 08:54:07 +0000

In the end it seems to me that if medical specialist compensation exceeds that of PCPs then more individuals with choose the MS route and supply will drive prices down UNLESS there is more study, time and cost involved in which case they deserve more money I would think, or UNLESS access to these professionsis somehow restricted.

I have a question which I'm still wrestling with. Perhaps someone has the answer. Other countries such as Canada and Denmark etc. use combinations of public and private care, spend 50% of what the US does per capita and cover more of their population, yet have much better outcomes per the World Health Organization rankings where the US is ranked 37th of industrialized nations. How do they do this. What's wrong with the system here ? Why can't we replicate these results ?

By: medrecgal

medrecgal — Mon, 15 Feb 2010 07:15:24 +0000

All I know for sure as a coder (and as a patient, too) is that reimbursement for PCPs does, in fact, stink. I find myself wondering sometimes how it is that the dudes (could be “dudettes”, but statistically that's much less likely) with the big fancy equipment and procedures, who don't usually know much of anything about the overall patient (in a broad sense), get the most money for zeroing in on a much smaller target than the PCP. Like I've heard other doc bloggers say, cognitive services don't get diddly squat. (Some suggest it's the extra training, but that doesn't seem like enough justification IMHO.) The funny thing is, a few of the specialists whose blogs I've read seem to think there's nothing wrong with that system…(of course, why would there be when they're making the big bucks?) I think part of the problem, at least from a coding perspective, is that it is much harder to document cognitively based services than procedures. When a procedure is done, the note looks a lot different than one that's for an office visit where the doc is managing 3 chronic problems and perhaps something acute like a URI or an ankle sprain. I think even office procedures are paid better than the E/M levels per unit, generally speaking.

As for insurance companies…I think that whole setup needs to be blasted down to the ground and rethought. Nobody wins when they're involved except the companies themselves; doctors and patients both wind up on the short end of things in some way or other. (Though I also think the general cost of health care prevents many people from going without it even if they'd want to.) Do you think providers and patients would tend to show the good side or the bad one of human tendencies if the middle man was eliminated and payment systems were direct? (E.g., the provider would have a set fee schedule based upon either time or the specific service(s) rendered, and that's what the patient would pay, or else there would be something like a sliding fee schedule based upon ability to pay or maybe a “bartering” system where the payment for services wouldn't necessarily be monetary but something material like goods or services.) I certainly don't think our government would have our best interests at heart in trying to fix this broken setup we have currently…

By: Marie

Marie — Fri, 12 Feb 2010 00:58:16 +0000

"Good Conscience is Bad Business" Could there be a worse indictment of our morals than that statement?

Managed Care has been my career for 15 years, the last few in executive management. There are some very, very good people in the industry who truly care about the members. And there are some very, very bad people who have created the current morass of unpaid claims (due to inefficient claims systems), 'lost' appeals (per instruction) and abysmal customer service (low pay, understaffing and lack of training). I worked with one Medical Director who was so despicable I called him Dr. Evil behind his back. It got back to him and didn't do my career a bit of good but I'd like to imagine it made him think.

Probably not. But I was quite pleased, if unemployed, that he knew I despised him.

My point is this. As long as greedy human beings can make money with the status quo, it will continue. There are some solutions, but I have no power to effect them:

Create a national, equitable, transparent fee schedule.
Develop one universal claims software package that actually works.
Hire more staff, pay them better and train them well.
Hold people accountable for their errors.
Do not tolerate mediocrity.
Cap bonuses for CEO's.

That would just be a start.

I'm sorry Dr. Rob. But remember, doing the right thing always pays off in the end.

By: Rob

Rob — Wed, 10 Feb 2010 14:20:20 +0000

HITECH doesn’t inspire many docs. Most look at it with skepticism and suspicion. There always are hooks underneath the seemingly positive things. I’m happy about it, but it doesn’t make me happy about M’care at all.

By: Ileana

Ileana — Wed, 10 Feb 2010 10:27:25 +0000

Dr. Rob,

How does the HITECH act affect this? I am in a Healthcare IT course and we make a big deal about the huge incentives that will be given through Medicaid/Medicare.

I suspect that you will be able to show Meaningful Use by 2011. Are the incentives enough for you? Did they change the way you see the Medicare/Medicaid issue at all?

By: wolfbaby

wolfbaby — Wed, 10 Feb 2010 05:51:07 +0000

I don't know whether to cry or laugh at this post… as one who has gone to school specifically for billing and coding I have a complete understanding of what you are saying. The govt is literally driving PCP's out of business and increasing health care cost by there very actions…. i shrudder at the thought that they would actually pass a centralized health care system or one of the other insane bills they are trying to pass. Before they add more problems they need to fix the ones they have! instead of driving good doctors out of business. Do you know how many people I know that changed there mind about going to medical school simply because of all of the problems intailed in being a doctor now days? instead they end up going to school to be a radiologist or some other kind of tech and forgo med school, its a shame really