Health care?

[denverpilot]

Medicade made financial incentives to move all records to databases rather than paper files. They also demanded a move to a larger diagnostic code system. The apparent goal is to database everyone and "manage" everyone's health for them. Yes, it is part of change to mandatory health insurance.

Most companies that deal with Medicare (not Medicaid) and OASIS paperwork (must be completed "just so" or they may not get paid for seeing ANY patients that month) have completely computerized charting now also.

When one typo or charting mistake on one patient can mean government non-payment for ALL patients seen in a month, the paperwork becomes far more important than the patient, because one bad piece of paperwork can literally bankrupt the business if they don't have the free cash to cover a month or two of expenses while it's all contested.

 

[denverpilot]

I also feel that we will see a 2 tiered system in future, those with Medicare and Medicaid will see providers subsidized by the Feds, typical to how the VA works. The other will be for commercial insurance and will be managed by private physicians. Riddled with the problems it would create based on ability to pay, I see it as a possibility.

Talk to colleagues in Australia. You've just described their system.

There are Doctors who will take government coverage and Doctors who only take private insurance or cash.

Most people supplement the government coverage with private insurance so they can avoid the low-end Docs.

 

[JOhnH]

I also feel that we will see a 2 tiered system in future, those with Medicare and Medicaid will see providers subsidized by the Feds, typical to how the VA works. The other will be for commercial insurance and will be managed by private physicians. Riddled with the problems it would create based on ability to pay, I see it as a possibility.

I think that sounds like an excellent plan.
Let the government run a system that will provide adequate medical care for those that cannot obtain it anywhere else. But those people should be means tested.

Let private practices cater to whoever they want to. They can accept insurance or not.

If someone that can afford insurance decides not to, they get to live (or die) with their decision. Of course though, once they exhaust their personal wealth on medical expenses they would become eligible for the government system.

 

[Jthamilton]

I think that sounds like an excellent plan.
Let the government run a system that will provide adequate medical care for those that cannot obtain it anywhere else. But those people should be means tested.

Let private practices cater to whoever they want to. They can accept insurance or not.

If someone that can afford insurance decides not to, they get to live (or die) with their decision. Of course though, once they exhaust their personal wealth on medical expenses they would become eligible for the government system.

I think it would be an excellent system. There are plenty of providers who enjoy the VA model and the lack of headaches. Privatizing the other arm of healthcare would and could remove a significant dysfunctional portion (govt mandates). The entrepreneurial providers could really do well and probably find joy in medicine again hence hedging the impending shortages of physicians.

Wouldn't it be nice if we could test the means of those getting assistance now! Even drug testing would be nice since wage earners have to why can't federal assistance require it..but that's entire other argument.

 

[John Baker]

Email: the "snail mail" of the 21st Century.

People e-mail boxes get overrun with spam, to the point they don't bother with it anymore. It takes too long to sort through the junk to find pertinent e-mail.

About a year ago I started using my block sender option, which has cut the spam from about 30 or so a day to just a couple, but you have to stay on top of it.

If someone could come up with a way of sending messages that was spam free, or discover a way of returning spam in the form of a computer destroying virus, I think that they could soon be able to buy any kind of airplane they wanted, actually several.

-John

 

[JOhnH]

If someone could come up with a way of sending messages that was spam free, or discover a way of returning spam in the form of a computer destroying virus, I think that they could soon be able to buy any kind of airplane they wanted, actually several.

-John

That thought has occurred to me many times. I have often wished I could reply to some of that spam with a computer destroying virus, or a virus that would send out signals saying "here I am! I'm a spammer, come and get me" and the envelope would contain IP addresses, MAC addresses and links to their contact lists among other info.

 

[nddons]

Most companies that deal with Medicare (not Medicaid) and OASIS paperwork (must be completed "just so" or they may not get paid for seeing ANY patients that month) have completely computerized charting now also.

When one typo or charting mistake on one patient can mean government non-payment for ALL patients seen in a month, the paperwork becomes far more important than the patient, because one bad piece of paperwork can literally bankrupt the business if they don't have the free cash to cover a month or two of expenses while it's all contested.

Boy, single payer health care ought to be TONS of fun! What could possibly go wrong????

 

[Bob Noel]

If someone could come up with a way of sending messages that was spam free, or discover a way of returning spam in the form of a computer destroying virus, I think that they could soon be able to buy any kind of airplane they wanted, actually several.

As long as the spammer killer is smart enough to not kill zombies.

 

[Gary F]

We understand the risk of a single-payer system, but I still would prefer it to this stupid system in which we have to deal with all these plans. The insurance companies still manage to lower reimbursements each year, complicate things, and suck off money for the "middle man". Look at the money they pay their CEO's! I have 5 employees in my front office due to the complexity of all the medical (not to mention vision) insurance plans.

I enjoy your posts a lot, Weilke, and I agree with you on most everything!

Wells

Until the single payer plays by rules that are unacceptable then we're really screwed.

It is not that "medicine is practiced inefficiently". The PRACTICE of medicine is efficient, I feel. But the shenanigans of getting paid are quite complex, whether driven by insurance companies or the government. And to those on here who think that the current situation is a recent thing, driven by the ACA, that is not true. The whole EHR fiasco is a George W. program. And the ICD-10 changeover has been coming for years (despite my prayers that it simply go away).

Wells

Why is the practice of medicine inefficient? It's because it has evolved gradually from ancient times and was never designed to be efficient. We can redesign healthcare to eliminate most of the waste.

 

[Gary F]

I think it would be an excellent system. There are plenty of providers who enjoy the VA model and the lack of headaches. Privatizing the other arm of healthcare would and could remove a significant dysfunctional portion (govt mandates). The entrepreneurial providers could really do well and probably find joy in medicine again hence hedging the impending shortages of physicians.

Wouldn't it be nice if we could test the means of those getting assistance now! Even drug testing would be nice since wage earners have to why can't federal assistance require it..but that's entire other argument.

Those of us who have practiced in a VA hospital or clinic and the military medical system may have a better idea of the limitations of government run healthcare.

 

[Jthamilton]

Many of us have spent time in VA facilities in one way or another. That was no attempt to discredit your time or knowledge of the system. However it is the model that many facilities would be compared to in the given scenario. I tell my patients who are veterans to use their facilities as they have earned that right, hence supporting the care many receive.

I know of several physicians (damn good ones) of various specialties who threw their hands up and went to practice in the VA Admin because it served what they wanted in life. I also know the perception (mostly incorrect) of the providers when access is limited with the veterans assigned team or physician.

Remove VA out of the picture and try and convince me that govt. mandates are not the largest contributor to the demise of the healthcare model.

Tell me about another govt. run healthcare model efficient or inefficient and i can use that as an example.

 

[weilke]

Wells
Gotta disagree on this one! Primary care can be managed as efficiently as possible and you still cannot make a go of it. You can't see more patients and make more money, it only deepens the hole. Many primary care offices have Medicaid and up to 30% Medicare volume. Primary care shoulders the greatest amount of paperwork, prior authorizations and referral hoops then any other discipline and are reimbursed the least.

I dont even know how you guys in primary care private practice survive financially. We have at least the surgeries and testing to ties us over, but making your money one E&M code at a time would drive me to insanity.

As for the admin work load, that shouldn't be your problem in the first place. The only thing you should have to do for a referral is to put your signature under a letter with clinical information when you refer the patient out. Particularly the low-rent HMOs have successfully managed to dump their administrative work on you. The other problem of course are the patients who are unwilling to deal with their own insurance company. The only exemption in my experience are the military guys with Tricare Prime. They know how navigate buerocracy .

Our local competitor fixed his problems with the HMOs. He dumped all his HMO contracts and only works with PPO, indemnity and medicare. He is in his 60s and well established, decided that it wasn't worth a headache to deal with them. Good for us as for the time being we pick up all the HMO business, but one of these days I'll have to tell some of the most painful HMOs to take a hike.

 

[Jthamilton]

I dont even know how you guys in primary care private practice survive financially. We have at least the surgeries and testing to ties us over, but making your money one E&M code at a time would drive me to insanity.

As for the admin work load, that shouldn't be your problem in the first place. The only thing you should have to do for a referral is to put your signature under a letter with clinical information when you refer the patient out. Particularly the low-rent HMOs have successfully managed to dump their administrative work on you. The other problem of course are the patients who are unwilling to deal with their own insurance company. The only exemption in my experience are the military guys with Tricare Prime. They know how navigate buerocracy .

Our local competitor fixed his problems with the HMOs. He dumped all his HMO contracts and only works with PPO, indemnity and medicare. He is in his 60s and well established, decided that it wasn't worth a headache to deal with them. Good for us as for the time being we pick up all the HMO business, but one of these days I'll have to tell some of the most painful HMOs to take a hike.

That's the problem, we aren't surviving! It would benefit most specialities to help improve our reimbursement. Allow us to practice our full scope and refer only those cases where surgeries are a certain thing hence improving your Alls revenue. So many primary docs just refer ANY Ortho issue instead of taking care of them. I'm sure many orthos would prefer to see probable surgical cases instead of low back pains or twisted ankles.

I never claimed to be sane

This last week I have seriously started revisiting the cash clinic business model on larger scale. I believe it provides great avenue for many physicians in the last decade of their practice careers or those go getter newbies! I'm definitely not sane to be thinking of this again.

 

[Gary F]

That's the problem, we aren't surviving! It would benefit most specialities to help improve our reimbursement. Allow us to practice our full scope and refer only those cases where surgeries are a certain thing hence improving your Alls revenue. So many primary docs just refer ANY Ortho issue instead of taking care of them. I'm sure many orthos would prefer to see probable surgical cases instead of low back pains or twisted ankles.

I never claimed to be sane

This last week I have seriously started revisiting the cash clinic business model on larger scale. I believe it provides great avenue for many physicians in the last decade of their practice careers or those go getter newbies! I'm definitely not sane to be thinking of this again.

I advocate a system of health care delivery where specialists get involved much earlier than our current system. This would require removal of financial bias where physicians are compensated much more for doing procedures than evaluating patients. The hard truth is that primary care physicians are not as well qualified to evaluate the types of problems that specialists see much more frequently. The main problem is that there is way too much documentation overhead for a subspeciality evaluation under current rules.

The other thing that we need to accept is a two tiered system. One is private insurance where you get the services you contract for with an insurance policy. The other is a bare bones, highly rationed taxpayer funded system for the uninsured, a VA system for civilians as a safety net.

 

[weilke]

This last week I have seriously started revisiting the cash clinic business model on larger scale. I believe it provides great avenue for many physicians in the last decade of their practice careers or those go getter newbies! I'm definitely not sane to be thinking of this again.

I wouldn't do it on a 'larger scale'. The smaller the scale, the better. Small square-footage office footprint, at maximum one employee who can do medical assitant and clerical work. If you dont have to dink arount with insurance reimbursements and HMO referrals, you get rid of 90% of your administrative work: 'Hello Mr Dumbledore, the doctor will see you in a minute. I see we have your credit card on file, sign here, this is your receipt'. The rest of the time your MA can spend on getting vitals or setting up lab-work and referrals if need be.

Take your time with patients, charge what you are worth, dont put up with idiots and a-holes. If you listen to your patients and take your time, they will beat a path to your door.

If you have a bread job that doesn't come with a non-compete, I can see how one could start building such a practice part-time. The cost in a medical practice is personnel, equipment leases and insurance, real estate is cheap.

One of my co-residents put me up to that concept. He was an orthodox guy and opened a practice in Bedford Stuyvesant while he was still a resident and went full-time with it once he graduated. He did take insurance, but only one insurance plan. If you wanted him to see your kid, you had to change your insurance to that particular PPO or pay cash. His office was closed on fridays but he would see your kids on saturday evening if need be. Oh, and he closed the office for 4 weeks every summer so he could spend the time as a camp doctor upstate.

 

[Jthamilton]

When I mean large scale I mean large influence in the community and plans for expansion. The first clinic was named Grassroots Healthcare, we used old equipment I had from my start up years before. Found a empty dental office with 1400 square feet, did a few minor very inexpensive changes less than $10,000 in improvements. Staff include 1 nurse, 1 front office and 1 provider. It has grown to another provider and 2 nurses now. It can now provide me with perfect information to tweak the model. We started the business on $60,000 between 3 of us. I moved and had the sole practicing provider buy my portion out for what I had in it. Now that I see what is occurring with the healthcare insurance it only strengthens my beliefs that there this concept can work!

Amazing how little money you can spend on starting a practice when it's your own money! My first practice nothing was new except my building. I save tens of thousands of dollars buying used office and medical supplies. However my staff were paid well and they had benefits as soon as possible.

 

[Jthamilton]

I advocate a system of health care delivery where specialists get involved much earlier than our current system. This would require removal of financial bias where physicians are compensated much more for doing procedures than evaluating patients. The hard truth is that primary care physicians are not as well qualified to evaluate the types of problems that specialists see much more frequently. The main problem is that there is way too much documentation overhead for a subspeciality evaluation under current rules.

The other thing that we need to accept is a two tiered system. One is private insurance where you get the services you contract for with an insurance policy. The other is a bare bones, highly rationed taxpayer funded system for the uninsured, a VA system for civilians as a safety net.

The hard truth is that many specialist cannot afford to practice or maintain certain skills in the rural areas where many primary care practice. I too would advocate earlier intervention on many medical issues however when the closest interventional cardiologist or pulmonary specialist is an hour away by plane it isn't practical. I have Ortho 2 days a week, ENT 1 day every 4th week, thankfully we have full time surgeon and ob/gyn. The local optometrist does great job. When we don't have luxury of calling the specialist and just sending the patient over you learn to practice the broader scope of medicine.

 

[weilke]

Amazing how little money you can spend on starting a practice when it's your own money! My first practice nothing was new except my building. I save tens of thousands of dollars buying used office and medical supplies. However my staff were paid well and they had benefits as soon as possible.

Yup, a lot easier to do it with a reasonable budget if you stay away from consultants and equipment vendors. You can spend silly money to outfit ophthalmic exam rooms with furniture provided by the equipment vendors. Or you have the carpenter put a 3-drawer cabinet with a table-top on the wall for a fraction of the cost.

 

[Sleepingsquirrel]

Yup, a lot easier to do it with a reasonable budget if you stay away from consultants and equipment vendors. You can spend silly money to outfit ophthalmic exam rooms with furniture provided by the equipment vendors. Or you have the carpenter put a 3-drawer cabinet with a table-top on the wall for a fraction of the cost.

but what about......

http://www.youtube.com/watch?v=arCITMfxvEc

 

[Gary F]

The hard truth is that many specialist cannot afford to practice or maintain certain skills in the rural areas where many primary care practice. I too would advocate earlier intervention on many medical issues however when the closest interventional cardiologist or pulmonary specialist is an hour away by plane it isn't practical. I have Ortho 2 days a week, ENT 1 day every 4th week, thankfully we have full time surgeon and ob/gyn. The local optometrist does great job. When we don't have luxury of calling the specialist and just sending the patient over you learn to practice the broader scope of medicine.

Many if not most of patients transferred to regional medical centers do not require invasive procedures. Procedures are often performed unnecessarily for the financial benefit of those doing them. Telemedicine is underutilized with the impressive equipment that is now available. Many times I can advise the primary docs what to do to avoid an unnecessary transfer. Under current rules I get unlimited liability and no compensation for giving advice over the phone. We need to develop and integrated approach where physicians work together to share expertise. For the patients who need to be transferred having the specialist involved early can save time.

 

[mnewb1]

looking ahead to ICD-10 this morning, I think I'll be ready, but from what I am reading none of the insurance companies will. How convenient for them to have a new excuse to deny payments for an extended period of time.

After 10 years of hard work building a solo practice, this year might be my swan song....

 

[denverpilot]

Gosh, how odd that medicine was practiced in days before giant code books and broken insurance company computer systems.