A star is born!

Our very own Kelley Beloff was part of an NPR roundtable last night, watching and commenting on the debate:

"Kelley Beloff, who works in the health care industry and leans right, says tax rates are impacting her vote, "I am totally middle class...and the big thing for me was hearing Mr. Romney talk about bringing down our taxes. My husband owns his own business, and we pay those individual taxes, and it is very difficult at times to make those tax payments."

Here's audio:

The Myth of the "Richdoctor"

No, not the witchdoctor, the richdoctor. And what, pray tell, is this "richdoctor" of which you speak? Well, let's let guest-blogger and Medical Office Manager Kelley Beloff explain:

“Arizona Doctor says Obamacare will force him to close shop”

That is the headline of the article sent to me by a colleague. Is this true? Will physicians stop practicing if Obamacare goes into effect? YES. Physicians have been saying for years that there is too much government regulation and the pay is simply too low. They are simply tired of the intrusion by the government. But there is more to the story:

“Scherzer said he hasn’t been fined but he was audited by the Centers for Medicare and Medicaid Services several years ago and spent months awaiting their findings.”

This statement refers to the RAC, the Recovery Audit Commission, which are hired mercenaries that go into physicians’ offices looking for Medicare Fraud and have unrestricted power to fine any physician they find who has committed fraud, whether knowingly and unknowingly. The fines are extensive and have bankrupted physicians since the implementation. The “auditors” are paid a commission based on the amount of fraud found, thus the investigations almost always find fraud. This physician was very lucky that he survived the RAC: most do not.

“He also takes issue with the Democrats’ argument that much of the waste in the health-care system is driven by a profit motive on the part of physicians.”

Ah, the richdoctor syndrome. Notice "richdoctor" is one word. This is a myth built around wealth envy. It is this attitude that was behind the founding of the RAC (is it a coincidence that this was a favorite form of torture during the inquisition? Just saying). Anyway, back to those pesky richdoctors. I recently received a report stating that the average reimbursement of the average office visit code (99213) for physicians is $65.49. Yep, $65.49. That is all your physician gets for seeing you in a normal 15 minute appointment. This is the average, so some insurances pay less; Medicare is one that pays less. Medicare reimburses $63.74. But Kelley, you will say, that is $254.96 an hour, which is a lot of money to make in an hour. You’re right, but let’s look at a few factors:

Overhead:

1) Government has mandated that all physicians implement an Electronic Medical Records system by 2014 or face punishments. An average EMR costs $100,000 for installation and the first physician. Any additional provider costs between $30,000 and 50,000. That is the initial payment, there are yearly payments to update the software and keep it functioning.

2) Government has mandated that all physicians must have on staff a certified coder by 2012 or face punishment. The average annual salary for a certified coder ranges from $50,000 to $75,000. Once the mandate goes into effect, that figure will raise.

3) Any efficient medical office needs three staff members to every provider. Do the math for your physician. The average salary of medical staff is $30,000 (including benefits).

4) Patients enjoy a clean office with lights, restrooms, heat and air conditioning, exam tables, sanitary equipment, new needles, chairs in the waiting room, telephones, fax machines, computers. These aren’t free (to the provider).

5) Patients expect the medical office staff to bill their insurance companies, deal with any problems, see them promptly when they are sick, fill out their paperwork, and generally manage their healthcare, all without any cost to them.

Thus, all of the overhead expenses are paid by that $65.49. When this physician started practicing, the ratio of overhead to physician’s salary was 20:80. Today that ratio is reversed. Overhead in any medical office accounts for 80%. The physician, if he is lucky, gets 20%. So for math, 20% of $65.49 is $13.10, which is $52.40 an hour. This physician went to medical school for 4 years, internship, and residency for $52.40 an hour. And when Obamacare goes into effect the reimbursement rates will be LOWERED. Why would any sane person want to go into medicine?

“It’s interesting how every time someone has concerns or opposed the bill you hear the Democratic party call the individual or group liars. It’s almost the mantra,” Scherzer said. “They’re providing disincentives to care that are making the practice of medicine repugnant.”

This point almost goes far enough: I would say IT IS THE MANTRA. The political environment has made it almost impossible to practice medicine. The government has put a wedge between patients and physicians and that wedge is MONEY. Patients today believe that they should not have to pay their medical bill, not their deductible, not their co pay, not their co-insurance, not their out-of-pocket expenses. NOTHING, NADA, NONE. My staff is harassed on a daily basis by patients who fight their bill with every ounce of their being; because the government is telling them that their health care is a RIGHT and these are just greedy richdoctors (see above). More and more practices, mine included, are putting anti-abuse clauses in their contracts with patients. That is, if a patient is verbally abusive with staff that is grounds for dismissal.

There is a physician shortage currently, and it will get worse. Physicians will retire rather than adhere to government take-over. What good will the “right to healthcare” be then, when there are no physicians willing to treat you?

Thanks, Kelley, for your insights and analysis. You’ve given us all a lot to think about.

[Hat Tip: Hot Air]

Medicare Advantage Plans: A MOM's Perspective

[Welcome Insurance Forums readers!]

"MOM" in this case being Medical Office Manager Kelley Beloff (whose previous contribution here still gets hits). Over the course of the next few days, Kelley will be sharing with us her unique and helpful perspective on these "bad boys" of the Medicare Supplement (MedGap) world:

Part 1 The Medical Office and Medicare Patients

December usually brings thoughts of holidays, snow, egg nog, and a reprieve from the normal hectic days we all experience. As a Medical Office Manager, however, December brings thoughts of dread because between Nov. 15 and Dec. 31, all Medicare Recipients have the ability to choose a new Medicare plan. With this choice will come chaos into my office beginning January 1. How can a person practicing their right to choose a new insurance be a problem for me? After all, it is their insurance, and it has no effect on me, right? No.

Before Medicare Advantage Plans, all persons eligible for Medicare had one insurance carrier. Medicare was handled through the government and everyone had a “red, white, and blue” card. When a Medicare patient came into a Medical Office, you copied the “red, white, and blue” card (and yes, it is referred to as that in the biz.) Unfortunately, when the government designed Medicare Advantage Plans, the government did not get out of the health care business, and is still handling Medicare. Now there are two types of Medicare plans, Traditional Medicare (administered by the government) and Medicare Advantage Plans (administered by private insurance companies). This has led to an unbelievable amount of confusion.

There are three types of Medicare Advantage Plans: HMO, PPO and PFFS. The HMO and PPO plans have a deductible (not the government Medicare deductible) and co-pays (not the government Medicare co-pays). There are also in-network and out-of-network policies, depending on whether the provider is contracted with the insurance carrier of a Medicare Advantage plan. If a provider is contracted with the government (Medicare), this does not automatically mean the provider is contracted with the Medicare Advantage plan. Finally, one cannot purchase a MediGap policy to cover the costs (deductible, co pay, co insurance) associated with this new insurance. With Traditional Medicare, after the deductible is met, there is a 20% co-pay on each procedure performed in the medical office. In order to pay for these costs, many Medicare Recipients have a MediGap policy. This is a private policy purchased to cover the deductible and co pays.

The last type of Medicare Advantage plan is a PFFS. A PFFS is a great plan, so congress had to change it. Current PFFS plans are non-network policies: the patient can see any provider, as long as the provider agrees to the PFFS fee schedule, which is the Medicare Fee Schedule. However, some providers are not trusting of not having a network and will not see PFFS patients. These patients are welcomed at my practice, as I find the plans very flexible and always timely in their payments (reimbursements). As I said, Congress has changed these plans so that, in the next few years, PFFS plans will have to be network-driven.

This section deals with Medicare Advantage patients and the medical office. At the beginning of each year, medical offices collect new demographic and insurance information on their patients to ensure correct billing for the coming year. In the case of a Medicare patient, the receptionist asks if the patient has new insurance. In most cases the answer is "no, I still have Medicare." If the conversation stops there, the physician faces major billing headaches in approximately one month (I will cover this more thoroughly in Part 3). Why? Because the patient can have either Traditional Medicare with or without a MediGap program or a Medicare Advantage Plan. That plan is a HMO, PPO, or PFFS, and each plan carries its own deductible and co-pay. Hopefully, the receptionist will still ask for a copy of the patient’s insurance card, at which time the patient will drop two or three cards into the palm of the receptionist. The “red, white, and blue” card, maybe an old MediGap card and a brand new Medicare Advantage Plan card. Now the fun begins. The conversation usually goes like this:

Receptionist: “Ma’am/Sir, you have given me a Traditional Medicare Card, a Medicare Advantage Plan card and an expired MediGap card. What insurance do you have?"

Patient: “I have Medicare.”

Receptionist: “Yes, I know. Which type of Medicare: Traditional or a Medicare Advantage?”

Patient: “There is no difference, it is all Medicare." (Then they go into a monologue about being a longtime patient, never being questioned before, their other doctors don’t ask these questions, etc.)

Quiz: Has the patient told us type of insurance he/she has?

If you said no, you are correct, and this is what faces us in the Medical field every day. These patients simply do not understand that there is a difference between Traditional Medicare and Medicare Advantage Plans. The biggest problem is seniors do not understand that the “red, white and blue” card is not needed with Medicare Advantage Plans. On the day they turned 65 and received that card, they were always told that this was their insurance card forever. I have worked in this field for 5+ years, I am a Certified Medical Manager and I cannot convince my patients, or even members of my own family, that with a Medicare Advantage Plan, their “red, white, and blue” card is no longer active. I have actually told some members of my family to put their “red, white and blue” card in their dresser and never touch it again.

If you would like to read a more in depth piece on Medicare Advantage plans, here's the link to a 49-page workbook on this very topic. The one piece not covered in this workbook is how the receptionist at the physician’s office is to know which medical plan the patient has enrolled for this year.

In Part 2, we'll discuss the Government and Medicare Advantage Plans. Stay tuned.

2 Cool Monday

■ Last week, Cato's Mike Cannon participated in a debate about the pros, cons and effects of individual health insurance mandates. This is important, fascinating stuff, and I highly recommend the video to our readers.

■ Longtime readers may recall our guest post from Medical Office Manager Kelley Beloff. Her practice has truly embraced health care transparency, and even makes its "menu" available to their patients. With Kelley's permission, this intriguing look "behind the scenes" is available for download here. Enjoy!

ICD-9, ICD-10: Whatever it takes...

Recently, we were alerted to a potentially useful "widget" which empowers health care consumers in making informed decisions. Kate Hersch wrote to tell us about a tool that gives consumers "ICD-9 code information in an easy to use, searchable widget."

The ICD-9 tool is designed to enable health care consumers to quickly and easily determine how and why their claims are paid (or denied). As the site notes:

"Many insurance claim denials are due to human error in recording the correct ICD-9 code in medical billing forms."

We've written before about these ICD-9 codes, but now there's a new kid on the block:

"U.S. health care providers and health plans have two years left to adopt a new federally mandated system of medical coding ... there is no federal funding for the computer upgrades needed to accommodate the new medical coding."

First, one wonders if HHS Secretary Shecantbeserious will also be selling, er, handing out ICD-10 waivers?

Be that as it may, the "new" codes aren't really "new new," as our resident Medical Office Manager Kelley Beloff graciously explains:

This article is outlining the next new cost for all of medicine in America. Physicians, hospitals, etc, are paid based on two sets of codes. The CPT (Current Procedure Terminology) codes (which are owned by the AMA) specify what procedure was done. For example, code 99213 is a mid-level, established visit usually lasting 15 minutes. However, to be paid, the physician must also include a diagnosis code called an ICD (International Classification of Diseases) code. Currently, America is using the ICD-9, or the 9th revision. The rest of the western world is using the ICD-10, or the 10th revision.

The ICD-10 adds thousands of new codes to the diagnosis arsenal and the codes are formatted differently. Why would this be a problem? Because physicians are spending hundreds of thousands of dollars, mandated by the HITECH Act, to convert their offices from paper to Electronic Medical Records, which must be done by 2014. All of these EMR'S are programmed to read ICD-9 codes, not ICD-10 codes. The set date for transition to the ICD-10 format is October of 2013. The cost to change all the forms, templates, and computer systems used by America's physicians will be in the millions.

When I went back into the medical field in 2003, the transition to the ICD-10 had already been set and passed. In the years since I can recall at least three different set dates for the transition. Each date has passed without the ICD-10 being implemented. In my opinion, physicians will rebel if they have to pay twice for their offices to be compliant with government regulations: first to install the EMR and then again to reformat the EMR they purchased 12 months before. I believe that this country will go metric before we go ICD-10.

Thanks, Kelley!

The (Doc) Fix is in....Or is it?

FoIB Holly R tips us that the so-called "Doc Fix" is in, meaning that (as we discussed over the weekend) providers' fees have once again been spared the axe:

"Congress agreed to a one-month delay in Medicare payment cuts to doctors yesterday, giving a short-term reprieve to a looming crisis over treatment of the nation’s senior citizens."

Except that it really doesn't. Let's ask Kelley Beloff, our resident Medical Office Manager, what this really means:

"What was passed was the extension of the current fee schedule that was supposed to expire today, to go to the end of this year. However, we are still facing a 29% cut on Jan. 1, 2011. That was not in this piece of legislation. While history is not always an indicator, Congress has let cuts go into effect at least 3 times since the cuts were started in the mid 1990's. I am anticipating the cut to go through on Jan. 1, 2011.

As to physicians opting out of Medicare. Now is the time to opt out. In fact I have sitting on my desk the CD with the forms in it to opt out of Medicare. Once the New Year begins, the physician is locked in for another year. So the physician has to ask himself, does he feel lucky, do I opt out on the chance the cuts will go into effect, or do I stay in and hope that Congress reverses themselves. My guess is that physician's will not opt out in the numbers predicted and continue to see Medicare patients, though on a more limited basis."

Gee, good news all around.

Thanks, Kelley!

ACO's: Accountable Care Organizations and Keeping Your Doc

Once again, we're delighted to present our favorite Medical Office Manager Kelley Beloff. Regular readers know that she brings to the table a unique perspective, and is willing to share with us some of the "backroom dealings" of health care. This time out, she reports on the devastation that looms ahead due to ObamaCare©'s new rules on Accountable Care Organizations:

Several months ago, Hank and I had a discussion about Accountable Care Organizations. What is this concept in Obamacare? As a medical practice manager, I actively read all aspects of Obamacare and how it would affect my profession. In April I attended a Medical Management Seminar, where this policy was discussed. I asked the lawyer leading the discussion what this guideline meant for privately owned businesses. He stated that no one knew what would happen.

Now we know:

"In 2005, more than two-thirds of medical practices were doctor-owned, a share that was largely constant for many years. By next year, the share of practices owned by physicians will probably drop below 40 percent, according to data from the Medical Group Management Association. Hospitals or health plans will own the balance of doctor practices."

I work for one of those doctor-owned medical practices, and Medicare Patients currently account for approximately 20% of the practice. If our practice is not purchased by a hospital before Jan. 2012, my physicians can no longer get paid by Medicare for treating Medicare patients. As with most micro and small businesses, we operate on a tight profit margin. A loss of 20% of our revenue is enough to cause our business to fold. So we have two options: go out of business in Dec. 2011 or negotiate with a hospital to purchase our business. This creates a buyers market, so hospitals can name the price and the physician has to accept or go out of business. Physicians will be forced to accept the pay from a Hospital, or go out of business.

The government, through legislation, will cause the demise of privately owned physician practices.

Physicians are already opting out of Medicare. Opting out of being in network with Medicare. Opting out of treating Medicare patients.

Currently "Medicine" is the only business where revenue is regulated by the Federal Government. In 2012, your medical care will be regulated by the Federal Government through Hospitals.

This is short post because the article says it all.

Thanks, Kelley!

Capitation, Rationing, The Rain, The Park, and Other Things

Kelley Beloff recently published an important and fact-filled post on physician reimbursement: specifically, fee-for-service vs. capitation.  I think this is an extremely important topic on its own, and it’s also important because it ties to many other key topics in medical delivery and finance – e.g., utilization management and rationing.  I expect we will be seeing much, much more on these topics.  Of course I can’t resist adding my 2 cents.  (Well, it started as 2 cents.  Sorry.)

The Irish playwright George Bernard Shaw was the author of many sharp opinions in the late-19^th and early-20^th centuries - opinions that often stung the comfortable classes of his time, and can still make us moderns uncomfortable.  I quoted Shaw when commenting on Kelly’s post about capitations:

"That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking bread for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity."

I think this insight is noteworthy.  It comes from the 100-year-old diatribe that introduced Shaw’s play, “A Doctor’s Dilemma”.  Shaw’s point was that fee-for-service payment is incentive for a physician to do more.  But doing more can also mean marginal or even unnecessary services that, as Shaw vividly pointed out, bring unnecessary risk of injury to the patient. 

We moderns find it easy to accept fee-for-service, because it is predominant and familiar, and we perceive it as normal; thus we tend to accept the personal risks that come from medical treatment.   On the other hand, we find it much easier to object to capitation – because we worry that capitation provides incentive for our physician to skimp on treatment.  Thus we perceive personal risk from receiving too little treatment ourselves.  This worries us, even as we read research that shows too much treatment is a general problem, not only for the public health but for the public purse, too. The difference in how these reimbursement methods are perceived is important to keep in mind when thinking about their pros & cons.  

Another commenter on Kelley’s post took exception to my quoting Shaw, based on Shaw’s rather repugnant ideas about what we today call medical rationing.  For example, Shaw said this:

"If you can’t justify your existence, if you're not pulling your weight in the social boat, if you're not producing as much as you consume or perhaps a little more, then, clearly, we cannot use the organizations of our society for the purpose of keeping you alive.”

In the intro to "A Doctor's Dilemma" Shaw stated the same thing another way:   

“In legislation and social organization, proceed on the principle that invalids, meaning persons who cannot keep themselves alive by their own activities, cannot, beyond reason, expect to be kept alive by the activity of others. There is a point at which the most energetic policeman or doctor, when called upon to deal with an apparently drowned person, gives up artificial respiration, although it is never possible to declare with certainty, at any point short of decomposition, that another five minutes of the exercise would not effect resuscitation. The theory that every individual alive is of infinite value is legislatively impracticable

Note  “organizations of our society” in the first citation, and "legislatively” in the second.  Shaw was talking about what we now call government rationing of medical services. 

I think Shaw advocated his position for the same reason that the Obama administration advocates the same position.  That is, in order to have an affordable national medical insurance scheme, there must be some reasonable way to control spending.  Shaw concluded that to control spending the government must deny at least some medical care.  The Obama administration has reached the same decision. In other words, both concluded rationing is necessary. 

NHS rations more explicitly, e.g., thru "NICE".  Other countries ration less explicitly e.g., the queue.  In the U.S. we have rationed largely on price.  But you can be certain that rationing explains why the Obama administration is trying to sell Physician Advisory Panels as necessary under PPACA.   

Shaw advocated a national medical insurance scheme in the U.K. 50 years before NHS arrived.  He felt he had suggested a reasonable basis on which to deny care.  This is a very uncomfortable subject.  But I ask you:  how can a national medical insurance scheme succeed with limited resources, if there is no limit to the expenditure of resources on anyone?  In other words without rationing, how can any national medical insurance scheme be “legislatively practical” within “the organizations of our society” - - to echo Shaw’s terms?   

Yet the issue before Shaw was not simply financial.  It was - and is - a moral and ethical issue, too.  This same moral and ethical issue is present in today's debate about the future of our medical care system.  Advisers to the Obama administration such as Ezekiel Emanuel (Rahm's brother, btw) sound just as rational - and just as repugnant - as Shaw.  However, it's no use to pretend the rationing issue will not exist if we simply ignore it, or to pretend we can safely disregard influential points of view with which we disagree. 

If you are interested, I highly recommend this article: "Principles for allocation of scarce medical interventions" Govind Persad, Alan Wertheimer, Ezekiel J Emanuel; Lancet 2009; 373:423–31.   A link to this article is found within this earlierInsureblog post.  

Movin' on up....

It is with deep-felt pride and pleasure that we are able now to announce that our own Kelley Beloff has accepted the position of Medical Office Manager for a much larger practice, in...wait for it...Tampa, Florida!

The good news for us is that she'll continue as a contributing member of the InsureBlog team; her new position, both professional and geographically, will give her even more opportunities and insights to share with us.

Mazel Tov, Kelley!

The Doc Fix ISN'T in... [UPDATED AND BUMPED]

[Please scroll down for update]

As we've mentioned before, proponents of ObamaCare© planned to try a little sleight of hand with the numbers:

"In order to avoid "adding one dime to the deficit", Obamacare ... had to play shell games with the funding. One way was to cut pay to doctors who treat Medicare patients by 21%.

In doing so they stripped billions out of the cost of Obamacare by projecting a $200 billion savings ... The game plan was to add those billions back in via a separate bill termed "doc fix."

Of course, this "savings" was anything but, since the trick was to just add those dollars back in under a different budget line. The assumption was that there would be no actual cut. But we all know what happens when we "assume:"

"President Barack Obama is asking Republican lawmakers to approve billions of dollars in new spending to avert a scheduled 21 percent cut in payments to doctors who treat Medicare patients."

It's interesting that, as usual, PresBo is attempting to make this a Republican problem; last time I looked, it was his party that controls congress (and its purse strings). In other words, he decided to play chicken with the lives of some of our most vulnerable citizens, and then blinked.

On the one hand, the folks pushing ObamaCare© want us to believe that it will add nothing to the (record breaking) deficit, while on the other doing nothing to actually control costs. The result is that they failed to plan for the very real possibility (now reality) that their little legerdemain would fall flat. Faced with mind-boggling debt, responsible legislators simply put up the stop sign.

It's true that both parties have played this game before, but it's also true that the stakes have never been this high. That's what you get, one supposes, when "you have to pass it to see what's in it."

UPDATE: In the comments, Bob mentions that he "was under the impression the Medicare cut went into effect 6/1 when Congress went home rather than voting another extension. The doc fix was supposed to be part of the COBRA subsidy and unemployment benefits package."

Great point, so I asked our resident Guru, guest-blogger and Medical Office Manager Kelley Beloff for an explanation:

"On June 1st the extension of 2009 fee schedule ended and the 2010 fee schedule, with a 21% percent cut went into effect. However, CMS suspended processing all claims for 10 business days, that is until June 15th, in the hope that Congress would again, for the third time this year, extend the 2009 fee schedule. For example, it was extended on January 15 to April 1. Congress did not extend in time to stop the April 1st deadline and CMS held all claims the first 10 business days in April. At the last minute, the extension was passed for June 1 and now we are in the same situation we were in on the first of January and again on April 1 of this year. At this time, it does not look promising that the bill will pass. If it does not pass, then CMS will process all claims from June 1 on based on the reduced 2010 fee schedule. My revenue cycle has been a roller coaster this year; I cannot count on revenue coming in in a timely manner."

Dr Jerry Maguire?

About 3 years ago, our own Certified Medical Office Manager (and now co-blogger) Kelley Beloff put some major holes in the Myth of the Rich Doctor:

"I recently received a report stating that the average reimbursement of the average office visit code (99213) for physicians is $65.49. Yep, $65.49. That is all your physician gets for seeing you in a normal 15 minute appointment."

And out of that comes his overhead, including staff salaries, office rent, malpractice insurance premiums and, presumably, a little vig for himself.

Fast forward a bit, and we learn that not much has changed except, perhaps, a certain perception:

"What physicians are trying to tell us is that they don’t see themselves as necessarily any more responsible for health care costs than all of those stakeholders"

Which stakeholders include patients (among others) who are used to virtually immediate and unlimited access to health care. One wonders if there may be a correlation there with the cost of health insurance.

One problem, of course, comes immediately to mind: the only insurance product that effectively addresses this issue is about to be ObamaTaxed out of existence:

"Now, co-blogger Nate points out that "an HSA with anything short of max deductible and no contribution would pass," and that's a fair cop. But without the ability to sock away tax-advantaged dollars in anticipation of future claims, you're not talking "HSA" at all."

Kinda wish they'd read the thing, before they passed it.

Matt's Missed Mark

Sometimes I despair of the modern media. Case in point, Matthew Yglesias and his inane take on a recent Time article on the cost of health care. As co-blogger Nate pointed out, the magazine got almost everything wrong. But that doesn't stop the illustrious Mr Yglesias from piling on, only adding to the torrent of misinformation.

To wit:

"Time’s long investigation of American health care prices missed one thing: We pay our doctors way too much."

Really, Matt? That's what Brill missed?

First, though, it's only fair to point out that Mr Y acknowledges one rather obvious elephant in the room, one that the press routinely ignores:

"[T]he best deal of all goes to the biggest insurer around: the federal government"

This simple statement goes a long way towards explaining how programs like Medicare and Medicaid distort the cost of health care for the rest of us.

Even a blind squirrel...

Unfortunately, that's the  last time he makes sense. Consider this example of his craft:

"America has the highest-paid general practitioners in the world. And our specialists make more than specialists in every other country except the Netherlands."

So. What?

Hey Matt, ever hear of tort law? Malpractice insurance? RAC's?

In fact, our own Kelley Beloff destroyed this myth almost three years ago:

"Government has mandated that all physicians implement an Electronic Medical Records system by 2014 or face punishments ... Government has mandated that all physicians must have on staff a certified coder by 2012 or face punishment ... Any efficient medical office needs three staff members to every provider."

And the list goes on. Hey Matt, who do you think pays for all that?

But this barely hidden gem is the real prize of his vapid little excercise:

"If doctors earned less money, fewer people would want to be doctors"

Wow, Matt, that's some brilliant, almost Krugmanesque economic and financial insight there. Good thing we have a glut of practitioners to handle the influx of all those newly insured folks thanks to The ObamaTax.

Wait, what?

[Hat Tip: FoIB Holly R]

The Doctor will speak with you now

In light of the effect that the ObamaTax is having (and has already had) on physician availability, I've been taking a look at some interesting sales opportunities being pitched at agents (and others).

The buzzword seems to be "telemedicine" or "telehealth," and the idea is that you buy a subscription to a service that promises you near-instant access to a doctor (or, perhaps, some other health care professional) that can help you determine the cause of the problem, and even issue a prescription if needed.

I've seen two of these so far (and I'm sure there are others); one offered a webinar, and our own Kelley Beloff has graciously consented to fall on her sword participate in one for us. I expect that we'll see her post on this soon. In the meantime, I thought readers might be interested in some broad descriptions of this product:

■ One fee per family per month. At least one of these products charges a single fee, regardless of how many people are "covered" [ed: the "scare quotes" are there because this isn't really "insurance"].

■ No co-pays. This is sort of a virtual "boutique" type model, where one fee covers all services. The benefit, of course, would be that one avoids being nickel-and-dimed for repeat calls.

■ The Doc is always in. This seems sort of obvious: what added value is there in this type of plan if the doc is available only during "business hours?" Come to think of it, this may be a good supplement for folks stuck with a new ObamaTax-compliant plan's "skinny" network.

Of course, it'd be nice to know how much these things cost. While these will vary from vendor to vendor, the price points seem to be $10, $15 and $25 per month, depending on the different services offered. That could add up to $300 a year to your health care costs, but if it guarantees access to actual care, perhaps that's a worthwhile expense.

Something to consider.

Not tonight Honey, I have a 339.82

[Welcome LGF readers!]

[Another timely update from our Favorite MOM (Medical Office Manager), Kelley Beloff, MSW, CMM]

I recently attended one of my yearly Medicare updates. This one focused on changes in the coding for medical conditions in the medical field, known as ICD-9s.

Women around the world have now been vindicated by the world’s medical association. There is a new ICD-9 for this year, code 339.82: Headache associated with sexual activity. As a woman -- and for my long suffering sisters -- it is about time that the medical field recognized the condition of how the thought of sexual activity can bring on a headache. So, as a service to the many readers of Insure Blog, I felt it necessary to report this breaking news on the medical front.

Yes, Virginia, the headache is real.

Welcome Aboard!

It's our pleasure to welcome long-time guest-blogger Kelley Beloff as a regular contributor. Regular readers know her as our resident Medical Office Maven (here, for example, or here); we're looking forward to showcasing her interesting and unique insights on a more regular basis.

Her first post as an official blogger is coming up shortly, so stay tuned...

Health Wonk Review: Life's a Beach edition

Good morning, and welcome to this edition of the Health Wonk Review.

In casting about for a theme suitable to the occasion, my mind wandered a bit (as it's prone to do this time of year), and I flashed on a serene stretch of sand and crystal clear water (and no, I did not have my hands wrapped around an ice cold Corona).

And so, I figured I'd share some moments of calm as we plunge into the best of the blogosphere's posts on health care polity and policy:

■ First up, a blast from the past: Jared Rhoads has transitioned from the more traditional blog platform to the v-log model (Mazel tov, Jared!). He last hosted the HWR back in January of 2012. In this vid-post, he presents the Urban Institute's Howard Gleckman discussing the challenges of financing Long Term Care.

■ Next, Chris Langston (Program Director of the John A. Hartford Foundation) offers his take on how the Center for Medicare and Medicaid Innovation (CMMI) might improve its effectiveness.

■ Bradley Flansbaum thinks that maybe the P4P (Pay for Performance) train has lost its caboose. He points out that the P4P phenomenon isn't an exclusively American idea: the Brits have been at it for a long time, "with mixed results."

■ HWR co-founder (and all around mensch) Joe Paduda ventures into Workers Comp territory (watch out, Julie!), ACA plan rate increases, Medicaid non-expansion and a few other interesting tidbits in this eclectic (and interesting) post.

■ Health care guru Roy Poses is concerned about how much money is being thrown at the boob-tube over the past few years in attempts to influence the public's perception of ObamaCare. He's also leery of the anechoic effect (which he introduced and explained way back in '06: "Why is it that folks can behave like such miscreants and everyone turns a blind eye?").

■ David Williams offers us the transcript of a podcast he recently did with the director of a new, not-for-profit effort designed to provide unbiased information to help patients choose physicians. It's called "The Doctor Project," and David's interview provides some background and a progress report.

■ I refer to Jason Shafrin as my favorite health care economist for a reason: he knows his stuff. This time out, he explores how the ACA's Medicaid enrollment expansion has affected even those states which didn't opt in to it.

■ For some reason, I always smile when I see posts from Wing of Zock. Ann Bonham, PhD (chief scientific officer at the Association of American Medical Colleges) offers her insights on the need to address sex differences in pre-clinical research that relies on cell and animal models (Whew!). I say: Viva la difference!

■ Julie Ferguson is one of my very favorite blog-buddies: she coordinates the HWR, helps me out when I run into glitches with the Cavalcade of Risk, and always has interesting, thought-provoking posts. This one's sure to take your breath away, perhaps literally, as she presents a last letter from a dying miner caught in a 1902 collapse, and takes to task public authorities both here and in Turkey for failing to safeguard the lives of contemporary miners. 

 ■ Louise Norris is another great blog-friend, and this week she offers her perspective on reference-based pricing. She explains how it's really just another way of looking at the difference between in- and out-of-network costs, and that the patient just needs to be more aware of them.

■ Harold Pollack interviews Sabrina Corlette, a Research Professor and Project Director at Georgetown University’s Health Policy Institute. They discuss how the new health insurance marketplaces are actually working: how many have paid their premiums, differences between the kinds of available insurance plans, the likely impact of the “Cadillac tax” on high-expenditure insurance plans, and more.

■ Finally, our own Kelley Beloff (a Certified Medical Office Manager) posts about the reality of physicians' wages. Spoiler: they're not as great as you've been led to believe.

Thanks for stopping by, and please make sure to join us again in 2 weeks over at Joe P's place.

PSA: On Waiving Provider Fees

Not sure when this became "news:"

"Recent changes to policy and plan language and increased litigation by third-party payers suggests that out-of-network providers who waive co-pays and deductibles may be in for some rough sailing"

One supposes it's a symptom of ObamaPlan "skinny networks," but the concept is quite established.

I reached out to co-blogger Kelley Beloff (herself a medical office manager), who confirmed that "you cannot routinely waive any portion of a patient's responsibility. This is stupid, you are leaving money on the table and trains patients that they do not have to pay. Come to think of it, I have not heard in a while, "My other doctors don't collect a copay." Old news."

So there ya go.

Shecantbeserious Goes on a Medical Mystery Tour! [UPDATED]

Our favorite guest-blogger, Certified Medical Office Manager Kelley Beloff, is back, and has the scoop on the real life implications of the latest ObamaCare© goofiness: Medical Mystery Shoppers:

As part of my daily readings for my job as a medical practice manager, I came across this article from the New York Times, “U.S. Plans Stealth Survey on Access to Doctors.” The article discusses how the United States Government is going to use mystery shopping techniques to assess the wait times for new patients to get into a primary care physician’s office and if patients on Medicaid are treated differently from those with private insurance.

“Alarmed by a shortage of primary care doctors, Obama administration officials are recruiting a team of “mystery shoppers” to pose as patients, call doctors’ offices and request appointments to see how difficult it is for people to get care when they need it.”

Then the article prints out the script that will be used.

After I fell out of my chair laughing, I decided I needed to point out the error of the government’s ways.

This is how the government has the phone call playing out:

“Mystery shopper: “Hi, my name is Alexis Jackson, and I’m calling to schedule the next available appointment with Dr. Michael Krane. I am a new patient with a P.P.O. from Aetna. I just moved to the area and don’t yet have a primary doctor, but I need to be seen as soon as possible.”

Doctor’s office: “What type of problem are you experiencing?”

Mystery shopper: “I’ve had a cough for the last two weeks, and now I’m running a fever. I’ve been coughing up thick greenish mucus that has some blood in it, and I’m a little short of breath.”

In separate interviews, several doctors said that patients with those symptoms should immediately see a doctor because the symptoms could indicate pneumonia, lung cancer or a blood clot in the lungs.

Other mystery shoppers will try to schedule appointments for routine care, like an annual checkup for an adult or a sports physical for a high school athlete. “

This is how the actual call will go:

Mystery shopper: "Hi, my name is Alexis Jackson, and I’m calling to schedule the next available appointment with Dr. Michael Krane. I am a new patient with a P.P.O. from Aetna. I just moved to the area and don’t yet have a primary doctor, but I need to be seen as soon as possible."

Doctor’s Office: Dr. Krane is booked out for new patient appointments for three months. Before I can schedule you I need some information. What is the name of your insurance? Are you the subscriber? I need your social security number, birthdate, ID number on your insurance card and your employer for our insurance verification.

Mystery Shopper: "Listen, I just need to see a doctor. I have been in area for four months and I didn’t need a doctor until now, so just schedule me."

Doctor’s Office: Sir, you do not need to take that tone of voice with me. By federal guidelines in the HITECH Act, all physicians’ offices must verify insurance before any person can become a patient. Additionally, by the rules in the Red Flag rule, we must determine that you are you and not using a fraudulent insurance card. Now, if you would like to continue the initial intake…

Mystery Shopper: "I cannot believe you are treating me like this, I’ve had a cough for the last two weeks, and now I’m running a fever. I’ve been coughing up thick greenish mucus that has some blood in it, and I’m a little short of breath."

Doctor’s Office: Sir, did you go to the emergency room?

Mystery Shopper: "Why would I go to an emergency room, do you know the wait times there. I just want to see the doc and get some meds, why can’t you understand this simple request."

Doctor’s Office: Sir, it takes at least three days to verify insurance and as I said the doctor is booked out for new patients for three months. At this point I recommend that you go to the emergency room and then please call us back to start the process of becoming a new patient.

Mystery Shopper: "Listen, I can do the new patient appointment later, can’t I just come in to be seen?"

Doctor’s Office: Sir, I am sorry but by federal guidelines, all patients not seen by a physician in three years must be seen as a new patient. Our office is contracted with Medicare and these are the rules mandated by CMS. We will have to see you as a new patient and the doctor does not have any openings for three months. I must insist that you go to the emergency room. Sir your symptoms are very severe.

Mystery Shopper: "Listen, how about if I just pay you cash, that way my insurance company won’t know that I was seen."

Doctor’s Office: Sir, under federal guidelines I cannot have you pay for an appointment if we are contracted with your insurance company for a discounted rate. That is fraud under CMS guidelines.

Mystery Shopper: "Un freakin believable, so what I am supposed to do, just die. I cannot believe you people." CLICK.

The reason for the appointment is not relevant at this stage; the reality is that physicians are booked out for new patients anywhere from two months to six months. If an established patient called me with those symptoms, the physician would tell that patient to go to the ER. Physician’s offices are not the site for this type of problem.

The article continues:

“To make sure they are not detected, secret shoppers will hide their telephone numbers by blocking caller ID information.”

To ensure against identity theft, one of our first lines of defense is a phone number. If a new patient calls with a blocked number then we become suspect of the true intentions of the person calling. In gathering information to make a new patient appointment, a physician’s office will require an address, phone number of home, work and cell, as well as employment status.

And then there is this paragraph:

“Eleven percent of the doctors will be called a third time. The callers will identify themselves as calling “on behalf of the U.S. Department of Health and Human Services.” They will ask whether the doctors accept private insurance, Medicaid or Medicare, and whether they take “self-pay patients.” The study will note any discrepancies between those answers and the ones given to mystery shoppers.”

No reputable physician’s office will give out this information to a stranger. If I received this phone call I would ask for a name and reason for this request, since all physicians taking Medicare or Medicaid have already registered with the U.S. Department of Health and Human Services, thus this is a scam phone call.

“Federal officials said the initial survey would cost $347,370. …Jennifer Benz, a research scientist at the center, said one purpose of the study was to determine whether the use of mystery shoppers would be a feasible way to track access to primary care in the future.”

Ms. Benz, let me save you some time and our government some money. This will not produce the results you are seeking. I can give you your answer for free. There is a shortage of primary care physician’s because the payments from insurance companies, the government included, are too low. In fact, in another posting today, I came across this article which details physicians compensations by category. Family Practice is dead last with a compensation of $178,000. The average compensation of $65.87 from an insurance company to a doctor for a mid-level office visit will not motivate physicians to go into primary care. The compensation has been stagnant for over a decade and it is doubtful that any primary care physician will ever get a raise.

My practice’s specialty is not on the list for the phone calls, nor is Ohio listed as one of the States where calls will be made, but if I do get one of these phone calls it will make my day.

Thanks, Kelley!

UPDATE: Under intense pressure (ie someone finally figured out how bad this looked), HHS Secretary Shecantbeserious (et al) has apparently decided to deep-six the program.

Exit question: how much did this little escapade cost the taxpayer?

Thoughts from a Medical Office Manager...

[Kelley A Beloff, MSW, is a Certified Medical Office Manager. For years, she has dealt with the real world issues of HIPAA, PHI and other regulations that dictate how she must run her (very busy) physicians' office.

Today, she offers her insights -- and the benefit of experience -- to InsureBlog readers. Enjoy!]

When I got into the office this morning to start another day in a busy doctor’s office, I did my usual routine. Backing up the computer program, going on line to check my emails, and there it was: another article about the costs of health care.

As a Health Care Professional, I strive to keep up to date with all information relating to the health care field. This article was from USATODAY.com and titled “Shopping for Health Care Prices can be pretty confusing.” As I read the article, it was obvious that the author did not talk with anyone who actually works in a physician’s office, so I thought I would correct some misconceptions related in the article.

There is a quote from Dianne Kiehl, Executive Director of the Business Health Care Group of Southeast Wisconsin. Ms. Kiehl states that “(i)f you walk into a (doctor’s office) and ask, ‘What does it cost?’ they can’t tell you. (The medical industry)…is trying to keep this information a secret.” This statement is not only incorrect, but shows a lack of knowledge of the operations of physicians’ offices. Firstly, physicians and their staff are not clairvoyant, we cannot predict what treatment each patient will need prior to any appointment. While there are set fees, such as the office visit (CPT Code 99213), there are other factors which can influence the cost of an appointment: A patient can come in for a visit for an illness, but during the course of the visit the patient reveals that two days ago she fell and twisted her ankle. Suddenly, the appointment has gone from an office visit for an illness to a visit for an illness and a possible bone break or fracture. The appointment has become more complex, the physician needs to order an X-ray, the staff may need to set up the patient, and the appointment becomes more costly due to the higher level of medical treatment. This happens in our office frequently and this exact scenario happened to me with my daughter. Since each appointment with a physician is unique to that patient’s care, it is impossible to predict or “quote a price for care” prior to the appointment.

The article continues and discusses how “insured patients are going to spend more of their own money, not just on premiums, but every time they go to the doctor, pick up a prescription or get admitted to the hospital”. This is true, but the article does not discuss the reasons why. One scenario that continues to happen in my office regarding patients paying more at their appointments has to do with Medicare versus Medicare HMO’s. Patients are not informed regarding the differences between the two, which causes major problems in the doctor’s office. First, patients believe that Medicare and Medicare HMO’s are the SAME. Time and again, I need to explain that these policies are not the same, in fact there are fundamental differences. Most common is the misconception that if a physician accepts Medicare, then they will accept the Medicare HMO. This is not the case: the physician’s office will only accept that HMO if the physician is contracted with the HMO’s company, e.g. Anthem, Humana, etc.

Patients do not know this fact until after they have signed with the company, seen their doctor, the doctor bills Medicare (since the patient thinks they are the same, the patient does not inform the office that they have a new insurance; it is not “new” to them), the bill is denied and the physician’s office bills the patient. At this point a month to several months have gone by, the patient has seen several doctors and suddenly has a pile of bills. Who does the patient blame: the insurance company, the insurance salesman, themselves, or the physicians office? I will give you a minute. The answer: the Physician’s Office. Why? Because we did not inform them that they were not covered under their “new” insurance (remember, they did not inform us of the change) and now we expect them to pay for their medical coverage. If they had known that the physician did not accept their “new” insurance, they would not have been seen, therefore it is our fault that they owe us money.

Secondly, the Medicare HMO may not pay for the services that Medicare was paying for and suddenly the payment for the same physicians appointment has increased. Again, who is to blame? Again, the Physician’s Office. “Why are you charging more for the same treatment I received last month under Medicare?” We are not charging more, your Insurance company is covering less of the bill. The charges are the same; there has been a change in how the bill is divided between the insurance company and the patient. This also relates back to why we cannot tell each patient what their care will cost prior to the appointment. Each insurance company pays based on it’s own internal calculations, and many time the physician’s office will not know the cost to the patient until the Explanation of Benefits (EOB) arrives in the mail.

What this article tiptoes around, but what I tell my patients, is that the patient is responsible for all the aspects of their own health care. This means understanding the insurance policy prior to signing anything, knowing if your doctor is in-network or out-of-network (i.e. takes your insurance or does not take your insurance) and finally, you the patient are ultimately responsible for all health care costs incurred by you.

I would like to thank Hank for letting me inform your audience.

Kelley A Beloff, MSW, CMOM

[ed: You’re welcome!]