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The Secret Back Door


The Secret Back Door

Go to a typical primary care practice (like the one I was in for 18 years) and try to find out the cost of anything and you will only get shrugs and obfuscation.  It’s not only that they don’t know what things cost, but the design of the system on which care is built goes out of its way to hide those costs.  Why?  Because it would be infuriating to people to see that their insurance pays 100% more than someone else’s plan and it would be equally mortifying to some physicians to realize just how bad their pay is compared to the docs down the hall.


Ask Dr. Rob: Medical Wreckords


Ask Dr. Rob: Medical Wreckords

Dr. Rob:  

Long-time reader, first time writer!  I want to know why it is that my doctor makes me pay to get my own medical records.  It seems like since they are my records, they should be free to me!  Can you explain this to me?

- Lucy in Texas

Thanks, Lucy, for asking such an astute question that is near and dear to my heart.

There is, in fact, a simple answer as to why doctors don't want you to lay hands on their medical records, Lucy.  It's the same reason you don't want your son's underwear after his first semester in college (known to have broken autoclaves):  they stink.

Why do they stink?  It's complicated.  The best way to see this answer is to look into the past.  Way back.


Adventures in Caring and Acting Affordable


Adventures in Caring and Acting Affordable

Some would think that since I no longer accept money from insurance companies, the Affordable Care Act would have less of an effect on me.  Those folks may be right in how it directly impacts my practice (since I don't know the actual impact on other doctors, it's not easy to compare), but there has been a significant impact.  I've got plenty of ACA stories.

But that's not what I am going to discuss in this post. 

My personal adventures with this law are far more interesting from the other side of the insurance card: the health care consumer (AKA patient).  It has been quite a ride -- one that has not yet reached its destination.


My Deadly Reality


My Deadly Reality

It looked so easy....  What could be so hard about catching crab in the Bering Sea?  Surely I am tough enough for that.

It looked so easy.... What could be so hard about building a practice compatible with the Affordable Care Act?  Surely I am smart enough for that. 





Is being in my practice something that saves money?  Some anecdotes from the recent past suggest the answer, giving evidence of significant savings, both financial and life quality, that my patients and their payors get.  This is an important case to be made to both the patients (who want to know if their $30-60/month is worth it) and payors (who could financially benefit from promoting this practice model).  I realize that this does not constitute a proof of concept, but it is not without meaning.



The Broken System - #4: Who Am I Working For?

I was recently posed with the question: "who do you work for?"

Since I am self-employed (as part of a partnership), the easy answer would be to say I work for myself.  That is not, however, what was meant by the question (and it would make a dull blog post if it was); the intent of the question was this: for whose interest am I most working for?  Who am I trying to please?  Who is my boss?

My answer?  I have many bosses:

  • My patients
  • The insurance companies
  • My patients' employers
  • Our business
  • The government
  • Oprah

So who really is my boss?

We all, in the end, work for Oprah.  That's a given.  I won't add any more to that as it is self-evident.

Being a primary care doctor, I would like to say that I work for my patients.  I would like to say that the only thing that matters is the health and happiness of the people in my care; but that would not be true.  I fight to keep this focus in my office,  but sadly it's still not the reality I live.  The reality I live is that of a planet being torn out of its orbit by larger, more powerful celestial bodies, all trying to make themselves the center of my universe.

Who is my boss?

Insurance Companies?

They certainly write a big chunk of my paycheck, commanding an increasing amount of my time.  I have contracts with insurance companies, agreeing to what they pay.  I follow rules of insurance companies to get the patients the care they need and what the insurers dictate, (which are sometimes at odds).  Insurance companies have more access to patient records than patients do, or at least they have easier access.  Insurance companies can decide if they will pay me or not, while the patient doesn't have that option.

Clearly, the pull of the insurers' gravity is stronger than that of the patient.  Clearly my patients are not my real boss.


But who writes the check for the insurance companies?  Employers do.  Employers dictate just how strict of rules the insurance companies will keep me under.  When they choose an insurance plan for their employees, employers dictate how much I can charge at each visit, what services I offer will be covered, what payment structure I will receive (capitated, fee-for-service, or high-deductible).  Much of what I can or cannot do is dependent on this decision.

If you asked employers, however, they would tell you that they are "at the mercy" of the insurance companies.  Despite the fact that the employer is writing a check to the insurer, the relationship is hardly one of control on the part of the employer.  As owner of a my own business I can attest to the one-sided nature of my relationship with my employees' insurance carrier.

Are my patients' employers my boss?  No, it's not really close.  Insurance carriers win that contest with ease.

Our Practice?

So what about my business?  Is my practice my boss?  Since I am a part-owner of my business, it is not quite as clear as it would be for physicians employed by a practice or hospital.  But the reality is the same in many ways.  My practice decides what contracts we will accept or reject.  It tells me if I am seeing enough patients, dictating how much time I am spending on each patient.  The practice pays for the medical record system, tells me when I can have time off and, in extreme cases, could fire me.  I certainly feel like a factory worker at times, punching in at the start of a long day with a conveyor belt of patients coming in so I can make money for "the man."

But who am I fooling?  Our practice is also totally dependent on insurers, going to great lengths to make what I do come out in a format that will please insurers enough to pay us.  Our practice could go broke should the government go through with its threatened cut to Medicare reimbursement.  We are a service industry, totally at the mercy of our "customers," or "clients."  Our business is but a pass-through vehicle for me to be paid by insurers and a front to let me see patients.

I work at my practice, but not for my practice.  My practice is not my boss.

The Government?

A significant percentage of my patients are either Medicare or Medicaid, so a large chunk of my paycheck comes from the government.  Many of the contracts I get from private insurers are based on a percentage of Medicare's rates, so the government is a very powerful force in determining what I get paid.  In addition, while I can opt out of any insurance plan if I don't like the rates, and have the option of negotiating a better rate, dropping out of government contracts is much, much harder.  There is also no chance for negotiation; I either take what they offer or don't have their patients.

In addition:

  • The government set up our procedure-driven model of care that has so favored the specialist over primary care.
  • They pay for enormous hospital bills but not (up until very recently) for me to prevent those enormous hospital bills.
  • The government sets the rules for documentation - those rules that force me to put so much meaningless information into the record that I can't find the useful information I need.
  • The government says that I can't send many kinds or e-prescriptions, even though doing so would be more secure and less prone to abuse.
  • The government sets malpractice laws that favor the accuser and so makes my nurses quick to send people to the ER unnecessarily and makes me increase my test-ordering and documentation to avoid litigation.
  • The government doesn't just tell me to get on electronic medical records (which I had already done), but gives me a large number of hoops I must jump through to prove that I am using them "meaningfully."
  • The government promises to make those rules more invasive and onerous as time progresses.
  • The government is supposed to regulate the insurance carriers, drug companies, and device manufacturers, many of whom are making huge profits during a time of economic crisis.  They "regulate" the drug industry, letting companies gouge with generic drugs, set prices inordinately high, and advertise directly to patients information that tricks them into believing things that aren't proven or that are patently false.
  • The government does nothing while more and more people outside the doctor-patient relationship plunge onto the system and plunder it for what they can get.

In short, the government stands watch while the health care system crashes and burns, the end result of which is that my patients are able to afford less and less care and I am too busy dealing with pleasing the system to give them the attention they deserve.

So who am I working for?  The one for whom the system is designed, the patient, is not just competing for my attention but is on the periphery looking in while I deal with these other entities.  The patient waits for an hour while I see extra patients and document profusely.  The patient can't afford prescriptions I write because the cost of drugs is too high or the drugs are denied due to insurance formularies.  The patient is afraid of me making a diagnosis for fear of losing their insurance.  The patient pays more and gets less.  I work harder and get less.

Who am I working for?  Far too many people who are making it far too hard to do my job.

I wonder what care would look like if I actually did work for my patients?  What would real care, not care that is torn apart by competing gravitational forces, be?  What would the chart look like?  How long would the visits last?  How much would the visit cost, and how much would drugs cost?

What would care look like if the patient was really who I was working for?

I'll ask Oprah the next time I get a chance.




Our Broken System - Example #2: Fat Cats

We have a cat.  He's fat.  His name is Zander, but we call him "Cat," "Kitty," "Loaf of Bread" (because that's what he looks like when he lies down and his fat spreads), lard butt, and "Fatso Catso."  In the picture above he is sitting on a puzzle because...well, because he's a cat.

There are two main reasons he is fat:

  1. He always wants to eat.
  2. We feed him too much.

Lest you think that we are bad cat servants (which is what you call people who own cats...I mean, people who live in the cat's house), let me paint a picture.  It's 6 AM and I go downstairs.  The cat immediately meows continuously until I feed him.  Then I go upstairs and do my normal morning routine.  While I am up in the shower, my wife comes downstairs and is met by meowing and an empty bowl.  We've learned that the cat's desperation for food is not indicative of his eating history, but my wife's natural reaction is to assume I did not feed the cat, and so give him a second bowl.  He will do this every morning, sometimes tricking us into feeding him 3 times.

The same routine happens in the afternoon (we feed him at 6 PM).  Around 3 o'clock, the cat begins his campaign of meow assaults on whomever he can bother.  If you walk to the door of the garage, he rushes to it, knowing that behind that door is his food.  Naturally, the only reason we would walk to the door is to feed him, right?

You get the picture.  He is deceptive and is difficult (if not impossible) to satiate.  We've gotten better at regulating his weight, but only at the cost of the persistent meowing which serenades 50% of our waking hours.

What does this have to do with our broken system?  Just change the food to money, and then think of all of the people who profit off of health care.

The second broken thing in our system is the fat cat.  A fat cat is a person, group of people, or company that gorges off of the money in our system.  Not everyone making money in health care are fat cats, most are simply getting money they earned from providing goods or services.  But there are a number of fat cats in health care who are being given all the food they meow for.  Here are a few examples:

Drug companies:  Why are drugs so expensive?  Because they can be.  If government and private insurers were not paying for most of the drug costs, who could afford $200/month for Lipitor?  People wouldn't buy most medications if they had to pay full price; the full price is impossibly high.  Even many generics are over $100 per month.   Despite this fact, the prices continue to be high and drugs continue to sell.  Why?  Because someone else picks up the tab.

It's as if the auto industry charged $500K for a new car.  Since nobody can afford this, the government mandates car insurance to cover most of the cost.  This brings the cost down to $20-50K for car buyers.  Or if Bananas cost $100 per bunch, but food insurance brought the cost down to $4.   If you sold cars or bananas, would you resist this model?  Would you trade a $500K payment from the government for a $20K check from the consumer?  No more than my cat would turn down the third bowl of cat food.

Hospitals:  Stents 'R Us hospital in our town just built a large cardiology wing costing 600 Gazillion dollars.  They did this using money from a procedure that has not been shown to prolong life or save lives.  Sure, stents make a lot of sense logically (opening a blockage is a good thing, one would think), but it is, as of now, an unproven thing.  But the marble lobby and the spiral staircase bear witness to the fact that they are not only paid for, they are paid for quite handsomely.  Eat up, kitty.

Ancillary Services:  Why does a CT scan in India cost a fraction of the cost in the US?  Are scanners more expensive in the country in which they are made?  Are the companies that sell the CT scanners warmhearted toward the people of India?  No, CT scans are expensive in the US because they can be.  Again, it's the fact that the third-party payors shield consumers from the exorbitant amounts charged that makes it reasonable to price CT scans out of the realm of affordability.  So what do the payors do about these high costs?  They pass them on to the taxpayers or raise the rates of the insurance policies.  It doesn't hurt them to pay so much, so they just keep feeding the kitty.

Doctors:  Yes, we doctors are not immune to eating the cat food.  Some docs pile up the number of appointments, giving less time for care so they can make more money.  We primary care docs are stuck with a decision between money and quality of care.  It's a terrible decision to have to make, and many decide that money is the most important thing.  Other PCP's just order a lot of tests from their own labs or x-ray facilities.  We did this for a while, and the seductiveness of the dollar sign was too much for us, and we got rid of our x-ray equipment.

Then there are the highly-paid specialists.  A banker friend of mine recently told me about a specialist who was complaining about how horrible reimbursement is, and how bad medicine is now.  Then he found out that this doctor earns over $750,000 per year.  Why do docs see so many patients that they can't offer good care, and why do other docs feel entitled to incredibly large salaries?  Because they can.  Someone keeps filling the bowl.

I think that the biggest cause of this gluttony is the third-party payor system which hides the cost from the consumer and gets us all used to the idea of paying for all that cat food.  How many people are getting rich off of medicine?  How many professions wouldn't exist without this all-you-can-eat buffet of cat chow?  How many companies are rewarding investors with huge profits because their devices or drugs are paid far above their cost of manufacture?

All of this money is thrown at care, and what does it get us?  Does it get us better care?  Does it get us longer lives?  Does it get us happier patients, or satisfied doctors?

No, it just gets us a bunch of lard-butt kitties meowing for more to eat.


Zander appreciated the comfortable spot we made in the back of his minivan.



Broken System: #1 The Distance Between Work and Pay

I think people missed my point.  Let me say again to those who misunderstood my last post: I am talking about the health care system being broken, not health care itself.  Our system is broken, which means that the money put into it is being wasted in staggering amounts.  Yes, we are getting some amazing results in regards to the care itself, but those happen despite the system, not because of it (most of the time, at least).  My first item of broken-ness will make the point.

Our office is not getting paid this year.  We used our credit line to fund my last paycheck.

Bad business?  Not at all!  We have worked very hard, seeing lots of patients in the usual surge that happens at this time of year.  So, one would expect, more work means more pay, right?  Not in our system.  While we do collect some money from patients up front, most of our billing goes to a third-party (insurance or government), and in many cases a fourth party (supplemental insurance).  The most important bill we send for our work goes to the "carriers," not to the patient.  We have all accepted this as the norm, and it may be the only way to do health care in some circumstances.  But this year there is a major glitch in the system.

I was actually not 100% truthful in my statement about who we bill.  The truth is, we don't actually send our bills to insurance companies.  Since there are a gazillion insurance companies, all with different contracts with different doctors, we actually send them to a clearinghouse.  These companies (not to be confused with those who present giant checks at people's doorsteps) take electronic submissions from doctors' billing systems and re-routes them to the appropriate insurance vendor.  This saves us the hassle of remembering where to send each bill, which would be nearly impossible.  They do take a little bit of our money in the process, but the time it saves us is worth it.

Assuming the clearinghouse gets it right and sends the bill to the proper place, the insurance company then either pays on the claim, or denies it.  The news of their decision then goes back through the clearinghouse and to us.  If it is denied (which it often is), we figure out why that happened, and whose fault it was.  Sometimes the insurance company made a "mistake" and denied it in error.  Sometimes the clearinghouse sent it to the wrong branch of Blue Cross or got our identifiers wrong.  Sometimes we submitted it using a bad diagnosis or other technical error.  Sometimes the patient forgot to tell us their insurance changed or lapsed.

This is the day-to-day complexity of medical billing in our system.

But things aren't working this year.  The problem is in the clearinghouse part of the equation.  As of January 1 there was a new standard that clearinghouses had to comply with, called the "5010 of the x12 HIPAA transaction and code set standards."  It puts me into a dazed stupor when I read the explanation of just what this is, but the HIPAA part has to do with patient privacy, so I suspect this is a patch to some privacy leaks in the billing system.  This also has to do with the change to ICD-10 (another broken thing I'll hit on in future posts), which is the code we have to use to submit our bills to the clearinghouses and ultimately to the insurers.  The problem is, many of these clearinghouses are not compliant with the 5010 rule.  Since it was a government rule dealing with HIPAA and since these clearinghouses are not paid if they do not run through transactions, I assume it was a highly complex and confusion standard.  In other words, they had a hard time doing all the things the government required.

But the upshot of this for us: nothing is going through.  Nothing.  And that means that we don't get paid.

Word on the street is that this is a nationwide problem, and we aren't the only practice not getting paid.  The insurance companies have no problem with this, as they are hanging on to "their money" a little longer.  The clearinghouses are frantically trying to fix this, but we're not sure when that will happen.  When it does, the queue for submission will be enormous, and so the payments will undoubtedly be more delayed.

All of the complexities in our system add cost, and the billing/payment system is mind-boggling in its complexity.  The bottom line is that there is always a long separation between the work I do and the payment I get.  There are many steps requiring many people and giving room for many problems.  These problems, of course, give more people work to do (all of whom get paid faster than I do) cleaning up the mess made by the confusingly complex system.

It reminds me of the game I played when I was a kid, where one person whispers "Llamas hygiene is next to godlessness" to the person next to them, and that person in turn whispers what they heard to the next person.  When it gets to the end of the line of people, the last person tells what they heard, usually something like "the elevator spins in an ornate bathtub."  This translation is often similar to what happens in our payment system, with payments not quite resembling the bill that was sent.  It is, of course, our responsibility to find any errors in the payment, re-submitting them through the chain to get the payment we should get from the billing.  It is our responsibility because everyone else got paid.  We used to have multiple employees to do this, but now have a company that specializes in this to do the job (they get a cut of what they collect).

This gives a glimpse into a reason the cost of care is so high.  I have to negotiate a higher bill than I need because of all of the other people earning money off of the transaction.  I have to count in the cost of the complexity of the system.  This happens everywhere a medical transaction is made, with a very large percentage of people working in health care only doing so because of the onerous complexity of the system.  All of those people between those who work and those who pay them will get more work to do if that distance gets further.

It's just like that game, except: "I worked hard" translates to: "Error.  Please resubmit with proper documentation and coding."

It's crazy folks.

It's broken.  It's also #1 out of 53 so far.