Home Forums Discussions General Discussion Who Speaks for PCP's and Their Patients???

I just copied this from another posting because I felt it needed it's own space. That other posting was good but the topic name was off target. So, let's keep this good conversation going here in it's own space..... Paul

How many of you would "really" be willing to help fund an informational group or PAC, that's only job would be to hit the media regularly, so as to inform the general public of our bankrupcies, over-load, anti-free market, and plight? We need to attact this on a national level and it would probably take all of us, hitting our various local media outlets, combined to pressure at a federal level regularly to finally make a real dent in the lack of public awareness. "Primary Care Physicains for Economic Equality and Reform... Yeah that's almost Pecker's isn't it??? lol).

The other thing is that we would need get our story striaght and make sure that a good part of it shows the public why hurting us really hurts them. We now don't have enough endocronology here in the Syracuse area for all the diabetics that need their services. The latest office to close says that they lost $300,000 in about that last 3 years and so had no choice but to close their doors. This is because the gave real care, took real time to see their patients and did lots of uncompensated work.

I think it is time for a primary care based organization that represents the real day to day hard workers like you folks. I feel that most of the state medical societies and the AMA don't care enough about PCP's. They care about specialists and maintaining the old broken system that allows certain high paid specialties to not PAR and keep this broken system going. So at some point very soon you guys need your own real champion and public support for change that includes you! Healthcare reform is on the public agenda but who is getting your side of the story out and speaking up for your needs? Trust me you don't want this big nasty thing getting "reformed" without having your voices heard and represented at that table. Goodness knows what that'll look like. "Oh we'll just finance reform like we do Medicaid, on the backs of starving and broke PCP's and other care providers"; trust me....

I don't really see anyone doing the right thing on any of this, do you? Do you think that the AMA is really going to get you guys a real "bump" in your E&M codes that are PCP only or finally create and get Medicare to pay for codes tha cover, getting paged and providing talk care after hours, all your phonecall, review and discussing and explaining labs time??? Try calling your lawyer and not have the chess clock start ticking, right?

Even the local Teamsters here were trying to simply win the right to organize and collectively bargin here in our state. But those of you who saw my post from the AAFP article about the FTC totally emasculating that GYN union, know that we need a new FTC and federal legislation that defines and protects your rights against these large greedy monsters. So what if you have a local union, if the moment you actual start to flex you collective muscle the FTC comes right in and shuts you down??? The only way that any of this is going to change is with a large public ground swell of support, and we better grab this opportunity now while it is on the greater public psychie.

So, are you folks really ready to waste your one spare evening a week, and your last few spare (do you have any left?) dollars on getting on this? Each one of you, your own local rep who needs to knock on a lot of doors, have them slammed in your face and come back for more???? we'll create a good stump speech so the message stays on target might we say.

Nancy does a small weekly peice on various health topics here with our local NBC affiliate on the lunch time news broadcast. I just got her to agree to talk about the closing of the Endo group here and their loss of $300K and how this affects real patients. That she needs to use her bully pulpit now and again for this. She started saying the public won't buy it because they think you're all rich. I told her to have them take a picture of our rusting out, 181K miles, '98 Grand Cherokee with the mismatching red door on it's green body, with it's missing front bumper. And that car was bought for us by my mom the widowed retired school teacher bought us when we had our first kid so the kid wouldn't be in a bomb of a '72 Plymouth Scamp that we used to daily drive back then. We couldn't then, as now afford such a car ourselves!

How can we organize and pull this off? I think it's gonna have to be grassroots. Doctor to doctor like on this board. You guys need to make friends with other stressed out docs in your areas, let the drug companies feed you now and then to make new friends and get reaquainted with old ones, and do this person to person, one at a time. Anyone really game? I'm scared I just got myself in over my head, because Bert is gonna want me to lead the charge....HEEELLLLLLP!!! Are you folks game???

Good Night and Good Luck
Paul

Paul,

You are so right. I think you should lead the charge. But, I will head up Maine. And, I am in for $375 annual dues if you can get 18 more doctors to commit.

And, I think it spells PC PEER.

Paul,

I just passed the 400 mark! WooHoo!

See if you can figure out this riddle?

There's 52 up and 52 down, yet only 1 person commenting.

I see multiple hits but few replys. Are we but sheep for the slaughter folks??? Who's got the guts to speak out besides me and Bert? I remember a very famous saying from world war II:

"When they came for the Jews, I said nothing; when they came for the gypies, still I said nothing; by the time they came for me, it was too late." So either step up or don't complain when you finally go under from all the pressure or they investigate your office and tear it apart. Come on folks; let's do some real coffee talk here.

Good Night and Good Luck
Paul

Paul,

I am in full support. I have had several editorials published over the years in Medical Economics Magazine. I was a very vocal member of our hospital staff until I got fed up with the poor support there. I do not belong to my county, state or American Medical societies any more because I have beat my head against too many walls in the past and I am tired. I am now just a black sheep. I wish I knew how one could light the needed fires but I do not. When managed care first became the trend, I begged my 4 partners not to fall into their lair but I failed and the group subsequently failed. I have basically resigned myself now to just being a grumpy, old fogey doctor who would rather be on my tractor cutting hay or talking to my mammoth donkeys than practicing medicine. Unfortunately, neither of those pay the bills. I have adjusted to raising jackasses rather than battling them. But, if you formulate a plan, I might find the energy to throw myself back into the manure pile.

Leslie

I am definitely with you, and I am certainly the Black Sheep of Brewer/Bangor.

Paul, I do feel your pain. It seems that the insurance companies are able to strategize en masse, while physicians are only able to stage guerilla assaults at the periphery.

Our physician organizations seem feckless and ineffectual at negotiating a better economic environment for us. One suspects that the higher-ups at the AMA and AAFP pay lip service to our concerns while they gaze wistfully at a Canadian-style nationalized health care system.

As a geographically isolated and "powerless" country doctor, my thoughts have been geared more toward opting out, rather than speaking out:

http://www.aafp.org/fpm/20070600/19brea.html

http://www.memag.com/memag/article/articleDetail.jsp?id=108870&searchString=cash%20service

What would happen if doctors just stopped taking money from third-party payors (as in the above articles)? Let the rich folks pay their concierge services! Let the poor folks go to the cash-only clinics! Let the insurance companies shrivel up on the vine. Let the bigwigs at the AAFP and the AMA go jump in the lake.

(Through fantasizing now)

Brian

P.S. - Leslie needs to post some pics of his donkeys!!

BC

One question concerning patients w/ insurance that see you out-of-network. What about their LABS??? It seems that the insurance companies deny the claim on a patient's labs if the physician ordering it is out-of-network. IF the patient isnt rather wealthy, how is he/she going to afford labwork. I dont know about you all, but the labs charge more than we do.

Wayne

This is way off topic but here is a link to the jackasses.

http://pets.webshots.com/album/560459782OeNKGc?vhost=pets&start=0

Leslie

Wayne,
We are in Northern Calif, about 120 miles north of Sacramento. In the Sacto area there is "THE LAB" company, which doesn't contract w/HMO's, etc. For example, a CMP is $35.00!!! We send some of our cash/high deduct pts there when they are able to drive that far. Even with the price of gas it's much cheaper than the other corp giants. I actually heard about them thru their radio ad. Maybe there are facilities like that out your way, but they obviously don't spend tons for advertising.

"THE LAB" sounds pretty cool. Lab costs differ from region to region; what percentage do your patients save?

There are people in my area who just get a catastrophic policy with a high deductible, and pay the rest out-of-pocket, and come out ahead. If the costs that we control could be lowered, more people would do this.

As far as prescription coverage goes -- love them or hate them -- WalMart in our area has their "Four Dollar List", which includes statins for four dollars, ACE-inhibitors for four dollars, SSRIs for four dollars. They even have omeprazole, metformin and glipizide for four dollars. Okay, maybe you don't get the latest and greatest brand name, but you don't need prescription coverage to get most kinds of drugs you need for the most common chronic health problems we treat.

I have worked at a cash-only clinic in the past. We saw working poor and middle-class patients and families. In my experience, when people pay their own money, they think harder about their medical decisions and lifestyle choices, compliance is improved, and they are more appreciative of the care they receive.

Brian

BTW, gorgeous critters, Leslie. I'm supposed to get a couple of donkeys in the next couple of weeks. I'll private message you some pictures when they get here. OK! OK! Back to the serious stuff...

Brian

Hey Brian, guess what?? I faxed "The Lab" after my last post to get an updated location list. I got an immediate call back from someone at Labcorp, who recently acquired "The Lab"!!! Geez, back to corp giants! BUT, this guy says they will create a new profile for our providers with pricing comparable to the old one. We'll see... I remain (as usual) skeptical. (They might be less accomodating if they find out we are a Quest draw station.)

Brian,
I totally agree in principle with your cash only and pay in full at time of service model, as long as we have the present broken system in place. Get these SOB's out of our offices and off our backs. But many of us are in areas where the next practice or doc is willing to cut our throats instead of stand together. I think opt out works best in well to do areas or those where there really arn't very many other choice such as rural ones. Even those few patients that we have become personally friendly with, don't want to go where their insurance isn't taken. God forbid they should have to deal with their own carrier 6-12 times a year the way we do now thousands of times a year for each and everyone of them. We would need to opt out as a group action and right now organizing such a thing is a violation of the crazy and misguided FTC's idea of "free-trade". We all cost exactly the same thing.... Oh Right; I forgot, that's free trade...

This is why, I still believe that the only way to break this strangle hold is for all docs, especially PCP's is to organize and unionize and to pressure for those rights to be recognized and protected by federal law, all plans even the gov't ones. Only as a joint action, with all docs leaving en mass as you put it so well (just like the carriers) can anything meaningful occur.

I'm an old stagehand who like docs and construction workers we frequently worked in many different places for many different employers, sometimes even on the same day. Theater set up that day, Met Opera or Soap Opera turn around at night. The employers used to and still do try to pull the old "private contractor" bit on us. But they call most of the shots and control our access to the work. A private contractor really can show up when he or she pleases, perform the work as they see fit as long as the deadlines are met. But the carriers and my old employers dictate way too many terms and conditions. Doctors, like stagehands are really "freelance" labor, not private contractors. That is the difference in terms all docs need to us. "I'm a freelance laborer, not a private contractor." Unless and until they drop all formularies, step therapies, and limits on what treatments you can choose, call requirements and a host of other things, you, by the definitions of the Dept of Labor are an enployee, not a private contractor. Worse yet, remember, every time they control your choices like this, the carrier is practicing medicine without a license. And yet somehow, King George saw fit to give only them a free pass on malpractice.

And as a relative new comer to this game, I also agree with Leslie that there were a lot of stupid, coopted, or mal-intented docs and societies that allowed things to get to the point that they are now. The docs of the 80's and 90's should be supporting the starving and stressed out docs of the 21st centry that they laid down this awful ground work for. Those of us today you are drowning in the wake they left behind. How did anyone get so stupid as to actually beleive that these greedy SOB's have anyone's best interest in mind, besides their own greedy selves? I just want to take the docs who work for the carriers as "advisors", committee chairmen, and "Medical Directors" and put them all in stockades for patients and docs to flail and mock in public. I know who my enemy and my master is....

I think that some how this issue of joint action has to be brought to a national spot light and quickly, while the iron is hot. Folks are talking about healthcare reform and we better get in there or they will do it without us. They will be mislead by those who don't have the patients' or the docs' best interest in mind, and PCP's will again have lots of busy work to do, with little or nothing to show for it. How dare any sane person support a system that has PCP's seeing more than 15-20 patients a day max??? Drive-by office visits averaging 7.5 minutes each!!! And then the insult of P4P because quality sucks so bad with those drive-by visits. It's my old Henry Ford thing. Crank up the assembly line so fast for your own short sighted greed and then get punitive on the assembly line workers because quality has gone to hell. You should have thought about that before you cranked up the assembly line speed so fast, right?

Now I've got a question for you and opting out. One of the other very large expenses in healthcare is vaccines. How do you bill and charge for such things? Kids get so many of these very expensive shots that we on our end have little control over price or access for. We even have carriers that are trying to use the terrible AWP thing as means of paying us less than it actually costs us to purchase the darn things on the open market. And don't patients still need referals for their managed care plans if and when they need a higher level of care? How do you and them get around all of that garbage? CAT Scans, MRI's, ortho, gastro, endo, oncology and all the others??? Without a referal isn't the patient SOL basically? I was thinking if we are not in a plan, can we still perform a prior auth or referal, charge for the service of doing such, so as to finally compensate us for all this extra busy work and get the patient the documentation they need to move to the next level? Obviously this charge would be paid for by the patient. $25-$50 so we can afford to have a staff member do all of them. But would most of the plans accept paperwork from an out of network PCP??? It would be glorious.

How come everybody else on everyside of this business, like software vendors, device manufacturers, big pharma, insurance companies, they all have a real free market; and we on our side of the system have been shoved in to this upside down, inside out, out of balance "free market"??? Couldn't you almost imagine hearing John Cleese explaining modern American healthcare from the Ministry of Uncontrolled Stupidity and Greed????

Good Night and Good Luck
Paul

Paul:

I can't answer all the points you raise, but:

I think that almost anywhere you live, there is going to be a segment of society that will want to deal in cash. I have dealt with them, and they are good people. If they exist in a certain number in a small town, I think they would exist in larger numbers in a large city. (I have personal experience with this phenomenon in a small town of 1,329 and a small city of 21,530).

As far as vaccine programs go, they are hugely expensive I know, and I tend to lump that into things that government does best, like building roads and fighting wars.

As to your questions about HMOs and referrals, I think the question you are asking is: how do we do "business as usual" when our practices are no longer doing "business as usual"?

Changing to a cash-only practice would be as drastic as switching your vehicle to run from gasoline to hydrogen: there are obviously lots of advantages, but the problems are new and strange. (Well, not *that* new and strange: cash-only was the standard until WWII and the guys in the above articles have been doing it for years; it would be interesting to pose these questions to them).

A "cash-only" practice would need to be run in a completely different way, and I recognize this might not be practical or comfortable for a lot of people. Still, for anyone that is ready to give the HMO's the heave-ho, this option is an available and viable one, at any time, and (I believe) in almost any population.

Brian

Here's another article about a cash-only practice:

http://www.aafp.org/fpm/20060200/642500.html

Brian

Brian,
I would absolutely love to give them all the big heave but what I'm saying is that most docs can't see past their next chart and car payment. The big factory groups here would continue to PAR and doing their awful drive by visits. Meanwhile, many people will bitch about waiting an hour and half, the 5 minutes of time from the actual doc, frequently not their own doc, but not do anything about it. They really aren't willing to stepp up to the plate and support a different way of conducting business by having to actually do some of the paperwork themselves or having to pay a bit more for the much improved quality of care. Especially in primary care.

As long as there are large numbers of other providers who are willing to cut their "competitions" throats, then we are never going to break this strangle hold that these SOB's enjoy over us. And I am very concerned that we just don't have the money in reserve (funny I wonder how that happened?) to survive the change in our practice and patient profiles. But it sure would be glorious and man does Nancy want to do something like that.

We have an awful plan here in NY, called the Empire Plan. It is the plan the state offers at the lowest cost to their own employees. It is so bad that it is "significantly" below present day Medicare by a double digit percentage! No joke. It's PPO, so most of these folks certainly could continue with their doc when he or she drops out of network by just absorbing a few hundred dollars a year deductable and some co-insurance. But what do these bozos do instead??? They continue to bounce around from practice to practice and will continue to do so, until each and every doc in town no longer accepts this crumby plan. We have seen it before as they establish here, there is just no loyalty around here to be spoken of. Now many of the practices that they came from deserve little or no such loyalty; but we fully expect to loose almost all of these patients as we start to widthdraw from this plan as well. They will just move on to the next practice in town that still accepts their cumby plan.

And this plan won't let you just close down your panel. They insist that if your panel is open to any other plans, then you must remain open to their plan too. That's one that always bothered me more than most others. How can any private company be allowed to reach outside the boundaries of their own contract to observe how you are conducting business with another private company as a private contractor? Is that not a violation of freetrade? What we do with in one contract with one company is none of their danm business at some other company. How and why does the FTC not see this as an infringment upon the freemarket and as anti-competitve? Their just a bunch of big business hacks there I swear.

Good Night and Good Luck
Paul

Paul:

Well, the thing about Dr. Forrest's clinic is that nixing the insurance agencies allows him to have nearly 100% collections with almost no staff. Overhead is drastically slashed, and he only has to see four patients a day to break even.

Don't get me wrong, Paul, it would mean a drastic (even scary) change for me to do something like this. I like my current staff and patient roster, and doing this would mean decimating my staff, and it would create a seismic change in my patient population. Also, I currently do hospital work, obstetrics, and endoscopies, which are uncharted territory in this model, and I would likely have to turn my back on some of these things.

However, if I am not reimbursed adequately for the work I do, why do it? If I have to maintain an oversized staff to wrangle reimbursement from a third-party payor, at some point I have to consider not working with them anymore. If my patients are forced to turn to a crummy PPO in order to receive care, why not provide an alternative?

>>Paul said: many people will bitch about waiting an hour and half, the 5 minutes of time from the actual doc, frequently not their own doc, but not do anything about it.<<

This is true, but it doesn't take "many" people to support a practice like Dr. Forrest's. Just four a day.

Yes, you would have to finance the change, but start planning and within a year, with some creativity, I'll bet you and your doc could be out of the rat race.

Then, when you leave the clinic at night, you will have collected a day's work for a day's pay. And, you can tell all these insurance weasels to go climb a tree.

Brian

Here's Dr. Brian Forrest's website.

www.acchealth.com

Disclaimer: I am not Brian Forrest, M.D.

I am Brian Cotner, M.D. :-)

Brian

Wouldn't it be possible to add elements of this to a standard practice? Say, offer this type of contract to the uninsured only. You dont offer it to any patient that is on an insurance plan that you are PAR with. IN NYC there are alot of uninsured folk--from the wait-staff at all the eateries to people working at some of the companies in the garmet district. And a lot more.

If you start getting enough of these patients, you then start dropping your less lucrative insurance plans.

Hi gang,

I'm in. I think my partner would be too.

It totally gores me all the articles in AAFP Journal about cash practices, while the AAFP and the NYAFP are busy lobbying for either a single payer system (while many of the members have opted out of Medicaid and Medicare - the two prototype government "single payer" systems)

We just got back from vacation - which is why I haven't weighed in on this earlier. More once I'm more caught up on the mail.

V.

I would be willing to help. We need to start lobbying as PCP's and physicians to stop this ludacrist system of insurance control over our market. Is there any other industry that has this type of reimbursement process? I will take cash any day and 20% of our practice is Uninsured. That comes with its own headaches and the right staff is needed to make sure that the cash is collected. Both Quest and Labcorp can do a special pricing to pass on the savings to the patients. The patient gets the discount if they pay at time of service, otherwise, we let the lab send them the bill. They do this once and never again, once they see the lab bill which is outrageously high, about ten times higher than they would pay us.
So definitely count me in as I am so fed up with this billing run around and doing work for which I am not paid for. I certainly have my share of nightmares with insurance companies and their so called "fee schedules".

Vinny and Dr. P,

I agree with both of your posts, naturally. I have stated earlier that I am in. Dr. P you are right about the problems associted with cash payments. Here I am with 50% Mainecare, 40% private insurance and 10% self pay. And when a self pay comes along and pays cash, I find myself giving them a rather substantial discount for paying up front. Of course, I am still, in the end, making more money in the long run since the insurance nightmare is out of the way, but that same self pay person who is self pay at K-mart gets no discount.

The frustration for me is there are already organized groups which should be fighting for exactly what we are talking about: The AAFP, AMA and AAP, etc.

Wcoghill:

I found reference to the technique you describe in Family Practice Managment magazine from April 2002 (forgive the extensive quoting but I couldn't link directly to the article).

Somehow, I had it in my mind that this would conflict with one of my contracts, but perhaps I'm confused. I will have to speak with my billing guru on Monday.

Brian

(quote follows)

"Our practice offers our uninsured patients a 30-percent discount on all office visits. The discount applies only to the office visit charge; we charge our regular price for medicines and tests associated with the evaluation and management (E/M) service because our profit margin on these items is so small. We simply charge the uninsured patient according to our regular fee schedule and then write off the 30-percent discount.

We notify uninsured patients of the discount policy when they make appointments and require that they pay in full at the time of the visit. Ninety-five percent of them are grateful for the discount and readily pay for their visits at the time of service. This not only enables our uninsured patients to obtain cost-efficient medical care, it also increases our practice's cash flow. Thirty-five dollars in our cash drawer is much more valuable to our practice than $50 sitting in accounts receivable for three months or more. The 30-percent discount is comparable to the discounts that our managed care contracts obligate us to provide to our insured patients, but we don't have to wait 15, 30 or even 90 days to collect it. "

Excellent info, Dr. P! I use LabCorp and I am going to look into doing this for my cash-only patients on Monday, oops -- Tuesday. Forgot the holiday (I'll be on call, so it didn't register).

BC

Cash paying patient.
My experience.
I have found it to be a rare event that even with a 30% discount, cash pay patients are difficult to treat. Non-compliance (maybe due to financial constraints). Drain on the sample cabinets. Unable to adequately treat. Many phone calls for free advice. High cancellation rates/highest no show rates. Occasionally, there are extremely wealthy patients that wants everything done (I've only met one in my 10 year practice).

AAFP publications regarding successes of cash micropractice is rather dubious. Many of these promoters of this type of practice is also on staff in Ivory Towers or have sugar daddies that support their practice indirectly.

So is there really anyone out there in Amazingchartland who has a successful cash only micropractice?

Preach it, brother. The AMA lost my dues years ago. They often send me JAMA by mistake and I take great relish in pitching it in the can, sight unseen. I don't even read the essay about the cover art anymore.

The AAFP makes their medical journal and their practice mgmt magazine extremely accessible to everybody online, and I have gotten a lot of good from both, so I feel like I get something from them in exchange for my dues.

However, I know of nobody in "organized" medicine who has anything bold or creative to say about ridding medicine of the economic and regulatory parasites that are robbing the vigor (and joy) of the profession.

It's a real shame: some of the best and brightest young doctors I know have fled private practice over the last few years to work in rural emergency rooms and acute care clinics. One guy I know left medicine to go to law school!

Brian

Roy:

Some other thoughts:

1. Non-compliance seems to me to be equal-opportunity. Some of my best insured and best educated patients think they know too much to take my advice.

2. Non-compliance due to financial constraints can be propagated by physicians. I freely admit that I don't have a comprehensive grasp of which meds are expensive vs affordable, generic vs non-generic. I am also sometimes unconscious of the financial status of my patient and I don't find out that they didn't fill my Rx because of expense until months later. I can tell you from experience that this is not a problem in a cash-only clinic; NOBODY is insured, and so you do get attuned to cost.

3. As far as the sample closet goes, mine is perpetually stocked with dust-covered bottles (with a few exceptions), much to the chagrin of the drug reps. I only use the samples to make sure someone can tolerate a medicine they can afford to buy. Otherwise, what's the point? I've tried to keep patients afloat in Lipitor for months at a time. One day, they come in and you don't have any. Better to start someone on a generic from the very first (thank you WalMart four dollar list).

4. Again, phone abusers and no-shows, in my experience, are equal-opportunity.

My phone policy is to let my nurse screen all calls first. If there is an issue that really needs to be addressed BY ME, I make a judgment about whether the issue is one that I should have addressed in the context of our last visit (in which case I call), or if this is a new problem (in which case they need to make an appointment). This would be my policy regardless. I would say that there might be less attempts at free phone advice if we weren't forced to run from room to room so much.

I don't have a lot of patience with no-show patients in my practice. However, again to be fair, I think the cash-only no-show patients might be (in part) a problem we create by policies that are hostile to patients who don't have insurance.

I will tell you who I find to be the biggest misusers and abusers of medical resources: Medicaid patients. Who is more likely to view medical care more lightly: the guy who pays $45 cash, or the guy who pays *nothing*?

BC

Brian (fellow JAMA tosser),

I've rid myself of Medicaid. I keep the Medicaid core provider agreement for the "charity slavery" the hospitals imposes on me at increasingly greater frequency. (occasionally some of these "charity" patients qualify for Medicaid which pays $20-30 per visit in the inpatient settings).

I'll have to admit, the greatest percentage of misusers and abusers happens to be Medicaid patients. Medicaid patients (generally) hold the record for most OTC meds overrides, largest medication lists, greatest no shows, greatest demands for formulary overrides, most difficulty getting referrals, dumbest middle-of-the-night phone calls, most complex billing process (not HIPPA compliant). The state often do not pay the 20 cents on the dollar and would rather spend money on useless "care management programs" and auditing the physicians. You know, even if they paid 150% of Medicare rates, I wouldn't be interested with all the hassles attached. Oh, also, the formulary for Medicaid happens to be the MOST generous when compared with the PPO market.

The only population with even a less restrictive formulary and greater privileges than Medicaid is ..... you guessed it..... the state inmates. I was medical director for our local state prison for nine years where inmates can get all the care they desire-- field trips to the dentist, specialists, hospital, etc. It's ironic that the correctional officers (state employees) are stuck with the worst access to care (state employees). Yes, if you ever need free medical care and catered meals, commit a heinous crime (must qualify for felony status rather than the slap-on-the-wrist crime).

I'll have to admit that my "cash-only" patients are generally those who have been in and out of the Medicaid experience. What I'm seeing is the extension of the byproduct that the government produces.

Anyways, I must agree with Brian. He is right on target in his assessment. That said, I HAVE HAD MORE ELVIS SIGHTINGS THAN TRUE CASH PAY PATIENTS.

Brian, we must get together to toss a few JAMAs some days. I have AAFP only for the CME purpose. But I have to rip out the CME offerings, advertisement, and ridiculous job advertisements out of the magazine before I get to the CME (LOL).

Dear Brian and Roy and fellow JAMA, MMA, and Pediatrics tossers: Sure Pediatrics is a good journal if you want to read 50 articles on the art, oops, EBM of treating hyperbilirubinemia.

I have over 50% Medicaid (Mainecare) in my practice. I really don't have a choice given my starting practice. Maine, home of the most Medicaid per capita in the country and the proud home of the $50,000,000 computer claims debacle where no doctors got paid for months and months as the claims were sucked into a big hole.

It is frustrating, because they do tend to be the most demanding. Not sure if other states of the Preferred Drug List, but it is a nightmare. While the intentions are good, it is super frustrating to finally be allowed to use Focalin XR but only then to be told how much we can use, i.e. can't prescribe more than 36 mg without a Prior Authorization. Take a look at one of the following criteria from Maine's Preferred Drug List. See if you can understand it, and try to imagine going through it in a ten minute office visit.

Seroquel 25mg is preferred and available without PA if the following conditions are met: a.) Either 65 years of age or older or less than 18 years of age, b.) dosage is for 3 or more per day, c.) Seroquel 25mg is in the profile within the last 45 days OR if any of the following doses are being used in combination with any daily dose of Seroquel 25mg: a.) at least 1.5 Seroquel 100mg tabs, b.) Seroquel 200mg tabs, c.) Seroquel 300mg tabs, d.) Seroquel 400mg tabs.

So, you know what I do? I write for 25 mg in the AM and 400 mg in the PM and tell the patient to throw away the 400 mg tabs.

But, I figure it's not the Medicaid patient's fault. It's, as usual, the federal government. If someone handed you the keys to a BMW 330xi, would you turn it down?

And, a bit off topic. Look what happens when 30,000,000 people want something. I am referring to the 14 year old to 21 year old young people who started with the illegal Napster and Morpheus and Limewire, which resulted in 99 cents songs from iTunes, etc.

Where are physicians? We are sitting on the medical ward with a very sick patient going through PubMed and finding the perfect article on the workup and treatment of secondary hyperparathyroidism only to find you can get it instantly through Springlink for the discount price of $35.00. And, that's for one day! And, that is supposed to decrease healthcare costs.

Bert:

That is a very interesting observation, but what are you suggesting we do?

BC

I'm actually sending out some emails. I have been thinking about this for awhile and figured it was time. <G>

You might check out the folks at the AAPS. Click on the link for Starting a Third Party-free Practice

www.aapsonline.org/

Interesting link, Dave. Thanks.

Brian

Way to go foks, now you're talking.

****Big Warning Here****
We were warned by our PO here in the Syracuse area that as of right now this brain trust of lawyers could not safely advise us to offer discounts to patients who pay cash at time of service. That as we speak there are a number of cases working their way thru the system, there is really prosecusion of docs for such things happening and that here in NY the state is even getting worse on such things. These were some very smart and knowledgable lawyers who spoke to us on this matter. I say; "don't do it" until someone writes law that clearly protects it... I consider you friends and don't want to see any of you get hurt.

This anti-free trade and treat all people "equally" has been so distorted and thrown out of wack that we can no longer make any "free" choices as to how to run our businesses like any and all other truely free market businesses. We do not offer a cash discount and until the climate changes drastically we won't. I'm not watching some moron from the FTC come in here and tear my office apart, shut us down, and take my wife off in handcuffs because we cared enough to do more in a single visit to assist patient accesss to healthcare, than these bozos do in a lifetime.
This is Bull, pure and simple.

Good Night and Good Luck
Paul

OK, this is not really on subject but, since I have finally completed my move into my new office (which is only 2 miles from my old one) I have to share this frustration. We learned last week that, in order to change our address with Medicare we had to download a form from the Internet, complete it and mail it back. Given the holiday, I did not even look at the form until yesterday....it is an 88 page monstrosity !!!!! JUST TO CHANGE MY ADDRESS!!! My office manager spent most of the day today on the phone with Medicare only to learn that it may take up to SIX WEEKS for my Medicare checks to catch up with me. How in the heck is a small office like mine with 60% Medicare supposed to survive 6 weeks with no money coming in?? The even more ridiculous thing is that all the junk mail produced by the pharmaceutical companies has already found me. I am so frustrated I wish I would have just closed things down and gone to computer school to learn to be an IT person...they charged me $95 an hour. Plus, I could have gotten all the good-looking men and be driving a Corvette by now (at least that is what it insuates in their TV ads.)

Leslie, who is no longer having fun in medicine.

Go back to the Medicare website and download Form UR12HAHA, or "Reimbursement Form for General Office Expenses While We Take Six Freakin Weeks to Process This Form That Will Actually Take Thirty Seconds to Imput Into Our Database". You won't actually get paid, but it will keep your office manager busy since she isn't going to have to spend any time posting Medicare payments for awhile!!

Leslie,

Wow. That's hideous. I wish you lived closer, I would have done your IT for free and let you use that money to hire an attorney. The problem is this information needs to get disseminated to public via newspapers or television or whatever. Actually, it's rather sad that sites like MySpace and FaceBook go up and thrive and we as physicians can't get one up and running.

Paul, I appreciate your input and warnings, but I am not going to stop giving discounts to cash paying patients. It's basically a sliding scale, and I treat some patients for nothing. If my Medicaid patients can be seen here for free and get all of their medications for free, I can and will discount cash paying patients. But, thanks for the FYI

Jumpin' Jehosephat! If you can afford it, you should DROP MEDICARE NOW! But maybe, unfortunately, they make up too much of your business.

From what I know, the rule is your charges should not be less than what you receive from gov't payers. So set your ratesto be no less than Medicare (still too low) fee schedule. Otherwise, they will demand the same discounts.