By J.C., on September 30th, 2009
One of the recent comments on this blog was in response to my post about whether patients should be able to direct their care. The “cyberchondriac” patient who comes armed with the latest and greatest in treatment options also reminds me of the patient who has done lots of research about his physician online. The advent of websites that “review” doctors and “score” them based on patient-physician interactions, impressions of care, or outcomes are a new thing that many doctors do not know what to do about.
Now more than ever physicians are being faced with the complete 360 degree evaluation of themselves. This evaluation comes from all directions. Insurance companies evaluate physicians in the form of denials, hospitals evaluate physicians in the form of peer reviews, patients evaluate physicians in the form of outcomes and overall patient-physician interactions. And now, we are being evaluated on the internet for all to see.
The truth of the matter is that there is not much we can do about it. It is essentially the era of the consumer patient and the freedom of information on the internet is merely a confirmation of that. But the problem with most physicians is that we are a hypersensitive bunch. We have become physicians through a ton of hard work, several admissions processes, countless hours of study, and massive personal and financial sacrifice. We seek praise and thus we don’t like it when people talk about us publicly.
The problem with physician websites is that they are just like any other review site. Whether it be for restaurants or hotels, you will undoubtedly have the consumer who thought it was a messy hotel room and that the food was disgusting. There is also the rare but enchanted consumer who loves everything about his meal and stay. There is no standard “Zagat’s” score for the physician and even if there was, it would undoubtedly contain many metrics that physicians have no control over.
The main difference between reviewing other businesses and physicians is that patient outcomes often have nothing to do with a physician but more to do with the patient. Many diseases are incurable and chronic and human behavior and genetics are at the root of many medical problems. Thus, patients who do not have great clinical outcomes are not the biggest fans of their doctors or the medical system. Don’t get me wrong, there are tons of patients out there with debilitating diseases who do not get better but still love their doctors. However, this is not the norm.
Physician reviews? We as physicians must welcome both criticism and praise. We must always know that at the end of the day, not matter what patients do or say, whether they are nice or mean, we are the ones who are looking out for them. That is what we signed up for. We can’t take it personally. We need to view everything as constructive and drown out the background noise.
By J.C., on November 3rd, 2008
If you are at the age where you qualify for Medicare, then you undoubtedly understand how difficult it may be to manage your medications and prescriptions. The government’s Medicare program is a terribly complicated thing comprised of four parts – A, B, C, and D. Medicare Part A is for hospital care. Medicare Part B is for physician visits, outpatient care, and durable medical equipment. Medicare Part C, also know as Medicare Advantage, is actually a special plan that covers most medical services and prescription drugs. Medicare Part D is the part of medicare that covers drug benefits. Medicare patients can voluntarily enroll in Part D and depending on the plan administrator may need to pay a premium or a deductible. Essentially, it is the government’s insurance plan for drug benefits that is administered by various other insurance carriers.
One problem with Medicare Part D is that it is difficult for patients to organize their medications, shop for different medications, and coordinate their overall drug benefits. I happened to find a relatively new company called Destination Rx that is trying to make managing the prescription drug benefit much easier for patients. I do not have a financial interest in the company nor do I use the company. But in the spirit of investigating this topic, I thought it may be worthwhile to point out some of the newer companies out there that may be of benefit to readers. It is interesting also to see how technology can empower the patient.
This is a company that essentially allows the patient to create an account and manage their prescriptions drugs. It is a free site that provides online shopping comparison for prescription drugs. If you are not yet enrolled in Medicare Part D their site allows you to do so. If you already take medication you can find out if there are lower cost drugs such as generic brands as well as mail-order and retail pharmacy prices. They have created what they call a “Medicine Cabinet” to allow you to manage your prescriptions. You can even look up medical conditions and find out what treatments are available so you can initiate a discussion with your physician about treatments.
Although I am sure that many sites and services like this will appear, it seems to me to be a great idea. I’m not sure how much traction it has had or whether enough Medicare-age patients are savvy enough to use the internet or have the resources to access the internet for this kind of service. However, what I like about this type of service is the tremendous cost savings that it might bring Medicare recipients. If retailers and pharmacy resellers are forced to lower prices do to competition and increased efficiency in drug selection, healthcare costs can decline.
By J.C., on October 30th, 2008
Some people have suggested that one way to prevent the wasteful costs of healthcare is to have a menu of treatment options, with their costs, that is presented to the patient. For example, when you are admitted to the hospital as an inpatient, the physician typically orders tons of tests, medications, and nursing orders. Most often you will likely have an intravenous fluid running, be on a stool softener, multivitamins, pain medications, daily blood work, etc. But all of these treatments and medications have a cost.
When I was a resident we had an attending on rounds who always would ask us if we knew what the costs were of every drug or treatment that we ordered. Most of the time we did not know. We ordered what was commonly ordered. We did not typically try to find out the cheapest alternative. Occasionally we would have a patient who insisted to know the cost of every medication they were receiving and all of the cheaper alternatives. Wouldn’t it be great if we could provide a menu of treatment options and their costs to every patient and allow them to direct their care?
There have been many times in my career where I felt that was the case. However, being in the hospital and seeing a menu of medications and their costs is not like going out to dinner and choosing off of a menu. Even though we describe the patient as the “consumer,” they really are not the consumer. They are the patient. They must consent to treatment and can choose treatment options, but they cannot “direct” their own care. If they could direct their own care then doctors would not be needed. As I’ve mentioned previously doctors are licensed to practice medicine and usually are board certified in their specialty. They have been trained for at least a decade to become licensed. Thus they direct patient care. Patients can choose treatments, but doctors ultimately are responsible for what happens to the patient.
In many ways, a doctor is a parent and a patient is the teenager. The teenager is almost a fully functioning adult, able to make their own decisions, but they are not old enough to be independent from the parent. A good parent makes decisions with consultation from the teenager. And ultimately the parent is responsible if anything bad happens to the teenager. There are many adult concepts a teenager cannot understand without extensive explanation. Even after such explanation they still may not understand. Thus it is not feasible to explain the pros/cons of every treatment or medication, the potential side effects, sequelae, the recent literature on outcomes, and the whole volume of information out there on every treatment and drug. Doing so would be unacceptable, and, even if you did do this, the patient may still not understand everything.
While a menu of treatment options and their costs may sound attractive in theory, it simply is not feasible and would clearly highlight that the patient is a patient and not a consumer.
By J.C., on October 21st, 2008
The theme of my last several posts has been the profit motive inherent in the medical system. Many parties appear to be responsible for this including industry and the physician’s lobby. I submit that the most responsible party is the consumer. The consumer is the one who demands the most advanced procedure, the best medicine, and the “best” doctor. The consumer is the one who demands the best prognosis and a return to the highest function possible.
One example of this is the cyberchondriac who comes in demanding the latest medicine or implant that they have seen on television. You explain to the patient that you feel that the generic medicine is just as good and is cheaper and that you are most comfortable with prescribing it because you are familiar with its side effects. However, they have seen the commercials and they have heard of the snazzy brand name. Additionally, they do not mind paying the exorbitant price of the brand name.
It is not unusual to also have the healthy young asymptomatic patient who would like a routine work up of all of his labs. My feeling is that if you are young and have no symptoms you should have the most inexpensive tests done, if any tests at all. If they are normal then you shouldn’t have anything done for a while. These patients are the kind of patients that want to stay on top of their healthcare and come in for unnecessary tests.
Sometimes there is a patient with knee pain without a history of trauma. The patient wants an MRI when there is ample evidence that the majority of knee pain resolves within six to eight weeks of conservative therapy including icing, NSAIDS, and activity modification. The MRI costs about a thousand dollars, but the patient doesn’t care because his insurance pays for it. Thus he insists to have one and if one is ordered there is a reasonable chance that it might show an equivocal signal in the mensicus. Then an expensive Orthopedic referral is made. If the surgeon is unscrupulous or if the patient insists on having surgery, an arthroscopic procedure is done. And the chain of expensive events goes on and on in this manner, costing the health system a lot of money for an issue that probably would have resolved on its own.
The underlying theme driving the demand of healthcare by the patient is a sense of entitlement. We in the United States don’t understand that if you travel halfway across the globe there are thousands of people dying everyday of disease caused from lack of basic sanitation. But when we have an annoying pimple or wrinkle on our forehead we want to pay several hundred dollars to have it zapped. When we have pain we want and expect our healthcare system to fix us. If we are not fixed then we blame the doctor and the system.
In the end, the most expensive thing is human resources. If we as patients make people work to improve our health it is going to cost money. That cost is worth it when the situation is dire. When it isn’t, the cost is wasteful. As a patient and consumer it is important to understand this concept–making the healthcare system work for you costs everybody a lot of money and makes the system more expensive. We are all intertwined in this manner, whether we want to believe it or not.
By J.C., on October 15th, 2008
I previously wrote about the EOB and how insurance companies try their many tricks to decrease reimbursement to physicians. Most physicians do not fight back. Some do. Medical Economics has highlighted the plight of one physician who has been fighting back. Their story is about a Chicago ENT surgeon who brought a lawsuit against an insurance company for bundling and downcoding claims. Apparently, the insurance company settled with him for $140,000.
As I mentioned in a previous post, bundling is when insurance companies downcode or combine multiple codes into one in order to reimburse the provider less. In this physician’s case, the insurance company was bundling endoscopies with office visits and was reimbursing for the least costly services only. Additionally, the insurer downcoded several codes based on software it uses and tried to say that the lowered reimbursement was a “negotiated write-off” as though the physician’s practice had agreed to it. This is exactly the type of thing I was referring to when I said that insurance companies “force” physician’s to accept lower payment. As this insurance company’s logic shows, failure to fight downcoding and bundling is equal to “acceptance” by the physician. Thus, if you do not correct it, it is assumed that you accept it.
Interestingly, the practice in question has a threshold for when to trigger legal action. When denials reach over $50,000 by one insurer, it triggers the next step in legal action.
Details are not given as to who actually pays for all of these legal costs. However, you can be sure that the addition of an attorney to your practice is probably prohibitively expensive. But when the potential windfall is large – this practice says that several hundred thousand dollars are collected each year via denial appeals – it may well be worth the investment.
If any reader out there knows of any stories like this, I would be interested to hear about them. It is not often that you find a provider willing to sue an insurer over downcoding. But I anticipate to see this gain popularity in the future.
By J.C., on October 10th, 2008
I previously posted about insurance companies and the EOB. I’ve been thinking more and more about this issue and have come to the conclusion that physicians must band together and file class action lawsuits against insurance companies in order to collect the reimbursements that they legally deserve. If you take a closer look at the dynamic between insurance companies and physicians, you will find that it is heavily skewed in favor of the insurance company.
Here is typically what happens. A patient sees a physician who has an agreement in place with an insurance company. The physician sends the bill or claim to the insurance company, and the insurance company remits payment along with an EOB. One hundred percent of the time, the insurance company does not pay the full amount of the bill. The physician typically accepts the payment and does not bother with trying to collect more. When the insurance company denies the claim, the physician may try to collect payment and resubmit the claim. But typically there is a huge loss by the physician who does not have expertise in collecting payment.
If you look closely at this you will find that essentially the insurance company short changes the doctor and does not pay the full bill. In any other consumer-vendor interaction, it would be a violation of payment contract. This would be equivalent to going out to dinner and then paying half the bill instead of the whole thing. I’ve never thought of doing that, and I doubt many readers have. In those situations, it would clearly be unacceptable. We know it, and the restaurant would know it.
What makes it any different if a doctor is not paid the amount of his bill? One could argue that doctors provide a community service, and that, if a patient is getting a free ride by the doctor, that is not such a bad thing. However, the reality is that it is the insurance company getting a free ride, not the patient.
What is going to change the system? Class action lawsuits. In my next post I will highlight some examples of how this could all work.
One could argue that taking such action would essentially bankrupt insurance companies and break the healthcare system. If I had to choose between squeezing doctors or insurance companies, you know who I would choose.
By J.C., on October 8th, 2008
In the medical industry, there is a dirty word called “bundling.” Bundling is the combining of multiple procedure codes into a general substitution code that ignores procedure code modifiers. Essentially, it is one of the ways insurance companies figure out how to pay doctors less. Here is an example of how the mechanics of reimbursement work in relation to procedure coding:
After a doctor sees a patient, he submits a claim form to the insurance company that lists all the procedures he did on the patient. The procedural coding method is quite complex and involves a series of modifiers when the procedure strays from the norm. For example, when you see your doctor for a general office visit, it is categorized as a simple, moderate, or complex office visit. The payment is different for each code, with complex reimbursing the most. Documentation for a complex visit is more extensive than a simple visit.
So how exactly does bundling work? Let’s say you go to your doctor for evaluation of hypertension. He notices that your pressure is abnormally low and that you are dehydrated. Thus, he decides to give you an IV infusion of fluid to rehydrate you. When it comes to billing, he has done three things with three different codes: evaluated you for hypertension, given you an IV, and done an infusion of fluid. The insurance company may try and bundle the two codes for IV placement and infusion together into one with the reasoning that an IV placement is included in the infusion code.
This type of bundling is widespread in every specialty of medicine and amounts to the simplification of multiple medical procedures into fewer. Thus, bundling is a technique used by insurance companies to mess with the coding system to lower reimbursement for physicians. As you can imagine, most physicians are not going to spend hours each day going over these codes and modifiers to see what they have bundled together. Some physicians actually test the system by continuously re-submitting claims with different codes until they get paid. In my opinion, manipulation of codes by physicians could be fraudulent – there is wide interpretation of how to code various procedures among the medical community. Many physicians feel that if insurance companies are manipulating codes, then doctors should fight back.
It is all a game of cat and mouse: the insurance companies bundle, and the doctors unbundle.
By J.C., on October 3rd, 2008
A friend recently asked me whether it matters if a physician is board certified in his or her specialty. For those of you who don’t know, the medical profession is governed by both a national and state medical board. In order to practice medicine, physicians must have a state license and a national certificate showing they have passed all the three steps of the United States Medical Licensing Examination. Once they are fully licensed general physicians, they typically obtain board certification in their specialty. Their specialty may be something broad, such as general family practice, internal medicine, or general surgery, or they may go on for further training to get subspecialty certification, such as in plastic surgery or cardiology. Essentially, at every step of their training, physicians need to pass an exam that says that they are competent according to national standards in that field. Board certification exists to ensure that there is a minimum standard practice among physicians in a specialty.
There are many physicians who do not have board certification in their specialty. This does not mean that they cannot practice medicine or their specialization. It may mean that they will have a difficult time gaining privileges at hospitals. It may also mean that the discerning patient may choose to go to someone who is more qualified. But, typically, it only matters if there is a complication or the patient is not satisfied with his or her outcome. If there is a lawsuit, it is likely that someone who practices a certain specialty without having the appropriate certification would be more exposed than someone who does have all the certifications.
One example of this is the notorious plastic surgeon on Dr. 90210, Dr. Robert Rey. I cannot confirm this, but I have read several articles that indicate he is not board certified, and he has been quoted as saying that he simply was too busy to get board certified. It does not surprise me that patients continue to flock to Dr. Rey for this services. Given his notoriety and fame from television, patients seeking a doctor to the stars will happily pay for his services.
From an economic point-of-view, this illustrates something very powerful in medicine – that reputation and business-savvy can trump qualifications. You do not have to be the best doctor or care provider in order to have a busy practice. It is well known in the medical community that, if you really want to find out whether a doctor or surgeon is good, you need to ask the key personnel who work with many doctors. For example, surgical scrub technicians know which surgeons have the best hands and the best intra-operative judgment. The average person watching Dr. 90210 does not know whether Dr. Rey is good or bad at what he does. He gains his reputation from the patients shown on television, his good looks, and the fact that he has his own TV show.
It makes me wonder why we have board certifications, after all, if the general public does not care much about it. Physicians in medicine seem to be chasing their tails getting more and more qualified, but perhaps this is all a futile endeavor.
By J.C., on October 1st, 2008
I’ve posted previously on how tough insurance companies can make it for doctors to collect their payments. Those of you in the profession know what I am talking about and are probably familiar with the acronym “EOB.” The EOB is the “Explanation of Benefits” that insurance companies provide to their patients and physicians.
If you are a patient, you probably only look to the bottom line or the far right which shows how much you owe the provider that the insurance company does not cover. You probably clearly overlook the fact that the amount paid by the insurance company is much less than what is billed by the doctor. When a physician provider receives the EOB, it looks a little different from the patient’s: there is usually an explanation of why the claim was not paid fully and/or why the claim was denied.
Unfortunately, the insurance companies have expertise in being as opaque and confusing as possible – the language in these explanations involves a mixture of legalese and what many of us would call “B.S.” It is the kind of language that confuses doctors and office staff and usually is only understood by the billing specialist at the insurance company. Additionally, it is a canned response by the insurance company computer system. Essentially, their computers flag certain errors or omissions and then send the generic computer response that is meant to deter the physician from resubmission or chasing the collection.
In a weak effort to provide some evidence behind my strong opinions, I found this article dated in August 2008 from the North County Gazette in New York. This is in reference to a health insurance company being fined $600,000 for failure to provide EOBs or adequate explanation of EOB denials to patients with their coverage. Interestingly, I could not find an example of a health insurance company being fined for providing inadequate EOBs to providers.
As I mentioned previously, the problem lies in the fact that the provider is good at his profession: providing medical care. He is not trained in how to maximize medical billing and how to chase down insurance companies to make sure they pay what they owe. It is a sad state of affairs and is actually a major reason why many new providers are opting to join a large managed care organization such as Kaiser Permanente, where they do not have to worry about scheduling, billing, EOBs, and human resources.
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