So yesterday’s rollout of the healthcare exchange website was filled with glitches. The White House compared the issues with Apple’s issues with the rollout of new technology. Who does he think he’s kidding? HHS Sec Sebelius said the glitches were a good thing because there is demand for the product. Wow. The site was overwhelmed with fewer than three million visitors-and we are supposed to be confident that the government will competently manage a system that will one day provide care for 300 million? Here’s one ‘glitch’ that no one is discussing. When a new health plan hits the market, the company running it has already built a network of providers by contacting all the doctors in the target area and offering them contracts and getting those interested credentialed and ready to see their newly covered clients. Do you know how many of the new exchange plans have contacted me to see if I will accept their patients? Not one. There are over three hundred doctors in my community and do you know how many of them have been contracted by the new plans? Not one…. Where are all these newly covered patients going to get their care? That’s a good question. It is also perhaps the biggest ‘glitch’.”
Initially, I posted a reply on his facebook that reads “I’ll offer my 16 year healthcare consultant advice for free here. They won’t. They’ll package it sweetly into a silent PPO (which they already try), or a TPP, and the health insurance ID cards will be inconspicuous so the staff thinks it a MCO you are already par with. IF they do offer a contract, here’s how we
negotiate this one. “NO” It’s a complete sentence. Reminds me of the former tort reform joke! Start advertising
now . . . “Who in Rutherford County will deliver your baby?”
Of course, my brain has been turning and burning since I read this. Dr. Boles’ point is valid. Critical. Crucial. I have been in the business of strategically managing the non-clinical side of private practice healthcare now for 16 years (eek!). I still have consulting contact with (to my count) 37 Physicians. Of those that I currently step foot into their practice locations, NONE of them have been contacted to credential with any of the plans under the new Healthcare exchange plans. ZERO. But, then, I thought – well, perhaps it’s because they are Medicare providers. But some I know, are not. Let me email those. In the last 6 hours, all but 1 of them have replied to my email with one word “No”. Well then, America – who exactly are these mystery Physicians who will deliver this new healthcare for all? The money you pay in for that service is paying for what? Paying whom? Physicians: READ THIS. If you are a current Medicare provider, they have already enrolled you. If they underwrite with another plan that you participate with – beware of the silent PPO game, or the TPP game that re-prices your contracts without approval nor agreement like they can, and just say NO. You can not see a patient for $38 and pay your staff! Of course, if you need someone to negotiate your contracts, or fill out your opt-out form via PECOS, call me. It. Makes. My. Day.
Consumers: let’s review. The money you and/your employer pays into an insurance company (be it commercial or mandated government exchange) is a contract between YOU and that company that you are paying for a service. Let’s say it’s $800 per month. Part of this $800 is paid by your payroll deduction (out of your pocket), some by your company (total compensation package). Okay, so you pay the tree of life or big blue $800 per month and you go to the doctor once that month. You pay a $40 co-pay and they pay your doctor – perhaps, an additional $49. $49 for your $800? But wait, that is only IF your ever-increasing deductible has been met first. (Still receiving $800 per month while you meet your deductible, they pay nothing until you reach this magic number & $1500-$5000 is now the norm in America). By the way, if you have not met your deductible, your Physician will bill for your service rendered in good faith, and will receive ZERO. Then, in 45 days or so, you’ll get a bill from your doctor. For some reason, most patients feel they should pay their doctor last, or a few dollars per month. Not me! I was gifted with a chronic illness by Walter Reed Army Medical Center, therefore, I pay my Physicians – first. When this happens, smart savvy practices, say, no more services until the medical bill is paid. Does not feel good, but is necessary to run a business.
Next you say, “self, let’s look at my healthcare insurance companies public listed earnings”. Say what? 2mil in BONUS to CEO’s? Yes, now let’s blame the Physician! Did you pass 3rd grade math? While we’re on this topic – quick, go grab your most recent “EOB: Explanation of Benefits” Some of them list CPT codes (Current Procedural Terminology), which must be used by Physicians to bill for the service they provided to you. In order to do that, they have to first purchase expensive Electronic Medical Record (EMR) systems (and we are talking $30-$80k!), learn the CPT codes that change with no notice (and most often do not even match what they did), pay a medical biller to pre-cert your visit by calling your insurance company where a non clinically trained non-English speaking person in India will answer the phone and either “approve” or “deny” your visit. When they deny, the doctor will pay his staff to call the healthcare insurance companies CUSTOMER to tell them no. The Physician has collected zero. He or she also has paid out an estimated $34 in staff costs to get to this point (not counting EMR software, their own training nor their electric bill). Patient has no care. Lose-Lose-Win. (Doctor-Patient-Healthcare Insurance Company). Here is where we have it all wrong. Patients/consumers: do NOT allow someone you pay a service to dictate your Physician’s treatment plan. Call them and ask them what service they are providing you for your money. They work for YOU. Let’s say they approve your treatment. It might look like this: Your doctor billed $130 for your annual well-woman exam, and your insurance company might-have-would-have-could-have paid $65, but you owe a $40 co-pay. After the billing department argues that yes, it was indeed one year and one day since your last well-woman exam, your doctor will get a check for $25. Physicians: an insurance company may say no but this means no to only to payment on behalf of THEIR customer – not to your treatment plan of YOUR patient. Feel free to use my best script ever (insert whatever procedure you are trying to get covered). Insurance rep: “no cover for a that a service”. Biller “what?”, Insurance rep: “let me transfer you to appeal department”. Biller “Practice Administrator – please pick up this call before I lose my mind”….wait on hold so long you forget who you were holding for…..then – “hello, yes, I am calling to get pre-approval for an in office obstetric ultra-sound”….Insurance appeal-or “I’m sorry, the member must report to ______ radiology for this scan. In office is NOT approved nor medically necessary and the patient may not have it”. Practice Administrator (okay, me) – “It will certainly be my pleasure to let your member know that you are failing to provide a service to her unborn child with whom she pays you for, and that her highly skilled Physician believes it critical because of this (insert diagnosis). But I understand, you are just doing your job. Now, I will do mine. What is your fax number? Yes, I need to fax you a consent form that will transfer the medical liability of both the patient and her baby to your company, because for the next two hours that she will have to wait to be scanned, my medically trained and board-certified ACOG fellow believes that her unborn babies life is at risk and I will not allow him to be responsible for your lack of concern or coverage…..yes, I have a pen handy for that approval number for in-office ultra-sound. Have a great day”. Work out a self pay rate for your patient and provide them with care. Look at fee for service models. Maybe then, patients will carry catastrophic only plans that pay for hospital stays, surgery, etc. After all, you gave up your 20’s and no one helped you pay for your medical school. Read this section on how to “opt-out” of this nightmare if you are a current Medicare provider:
“…(b) Establishment of a Provider Network- (1) IN GENERAL- Health care providers (including physicians and hospitals) participating in Medicare are participating providers in the public health insurance option unless they opt out in a process established by the Secretary consistent with this subsection. (2) REQUIREMENTS FOR OPT-OUT PROCESS- Under the process established under paragraph (1)–
(A) providers described in such subparagraph shall be provided at least a 1-year period prior to the first day of Y1 to opt out of participating in the public health insurance option;
(B) no provider shall be subject to a penalty for not participating in the public health insurance option;
(C) the Secretary shall include information on how providers participating in Medicare who chose to opt out of participating in the public health insurance option may opt back in; and
(D) there shall be an annual enrollment period in which providers may decide whether to participate in the public health insurance option.
(3) RULEMAKING- Not later than 18 months before the first day of Y1, the Secretary shall promulgate rules (pursuant to notice and comment) for the process described in paragraph (1).
(c) Limitations on Review- There shall be no administrative or judicial review of a payment rate or methodology established under this section or under section 224.”
Since the HMO’s saved us all – I feel quite confident that this new Affordable Care Act will work exceptionally well. Here’s what exceptionally well looks like in my opinion: There are always Physician’s who graduate in the bottom of their class, and who are not board certified (lest we suggest, double-boarded) who will bend over and take these bottom feeder plans and rates. They will look like the current Medicaid practices that we all know and can name for each locale. Locations that most of us would never step foot in.
If it were funny, I might have laughed at our highly intelligent and most competent government writer’s use of language in the employer categories. Smallest employer group (10 or less); Smaller (less than 20 more than 10)….Sesame Street did them good too! (Hint: this will force smaller companies to become smallest companies and let go of half of their employees to qualify.)
One last point for good measure. Childhood Cancer Warriors: are you aware that HB 3200 also outlines when and how the government can decide if cancer treatment is approved? First, we know what our current government thinks of childhood cancer (1 penny of every dollar allocated), so we can imagine where that leaves the decision of how this plan will decide to approve childhood cancer treatments. This plan, however, goes further – if over the age of 76, Cancer treatments will not be covered. I guess we should just bury everyone at 75. Think it’s not already happening? Really? Ought to call a friend of mine in TX. Single mother, age about mid forties – can not get her cancer treatment approved because “it will probably just come back”.
So, how will private practices survive? Without strategically fantastic professionally trained medical practice administrators, they will not. Wise Physicians recognize that the business side of the house is as important as the clinical. I visit so many practices where (when we had paper medical records) – the medical records clerk stayed long enough to work at the front desk. Then she worked there long enough to become the front office manager – and if they were lucky – stayed long enough to be promoted to the practice manager. The positives are – she’s loyal, knows the business well, and can speak words just as the Physicians might, knows the patients and has a cheerful sing-song voice. The bad news is – she most likely can not save you. Obama care and some before him, has put the practice of medicine in peril. Without strategic planning, forecasting, cash flow acceleration, a close eye on compliance plans (this year alone, major changes in (T)OSHA, OIG, HIPAA Privacy/OMNIBUS, HIPAA Security, HITECH, e-verify, New Hire Registry, State licensure, Sunshine Act, CLIA, COLA, EEOC, DOL, Meaningful Use, STARK, and we barely survived e-scribe) as well as the trickery contained there-in, private practices will not survive. Remember those Electronic Medical Record (EMR) incentives they promised if you just spent $60k on all the software, hardware and training? You know, the little big-brother game of “Meaningful Use”? Yeah. Well, they got their data – which they then used for the Affordable Care Act, and now the coffers are dry. SHOCKER. At least the practices that I had oversight of got $15k for year 1 stage 1. This will pay for the paper we had to purchase in a paperless EMR environment. That in and of itself might just kill me. Somewhere in Maryland there is a time capsule. In which has a piece of paper where I called this day back in 2003 when I had just watched in disbelief a failed tort reform. I wrote something along the lines of “healthcare in America – will become one of the “haves” and the “have not’s, be sure to be on the side that has (and I am not talking about money)”. One could say, I am ever so slightly, pro-physician. Why? Because socialized healthcare is NOT a good thing and there are so many great Physicians out there who could and do make a difference every single day. They are simply giving up in alarming numbers because their every move is dictated by policy makers that have no medical training. We have to do something or we are going to lose them. But, it’s all good in the hood, right? No one needs a doctor anyhow! Until something goes WRONG.
To read HB 3200 in all it’s glory
http://www.govtrack.us/congress/bills/111/hr3200/text. Please read it. The above are highlights from simply the first 500 pages of the Healthcare bill. Contact your Representatives and let them know how you feel about this. We, as a country, cannot afford another 1000 page bill to go through congress without being read. Another 500 pages to go for me!
America, WAKE UP.
Tiny disclaimer: the thoughts above are not those of Dr. Brent Boles, nor any current, past or future private practice physicians. They are mine alone. Those of you whose blood may have almost boiled, don’t even yell STARK. No contractual information has been disclosed.
Dear Charles Hemenway, MD, phD & Shirley Pulawski (author of the Article New movie portrays teen cancer unrealistically, expert says),
Woodard Girl Out 
