Home Forums Discussions General Discussion The Health Insurance Industry is a CARTEL

Folks,
I just copied this over from another thread because I felt it was that important enough to have a thread of its own. This concept just hit me before the weekend and has been bouncing around in my head gain form. Please feel free to chim in and have at it.... So here we go.

Al,
Could you find some really good cartoons or photos of the OPEC meetings with all the headgear and stuff. Now, I don't want to be seen as doing anything the least bit racist here; Some of our best friends and collueges hail from such parts of the world and practice such religions, I really couldn't give a hoot, god bless them one and all.

BUT it finally dawned on me that the insurance industry with its Anti-Trust waiver, that controls and restricts our free access to our own end-retail customers of our services, is really just a legislatively created "CARTEL"!!! And so I would really love to start portraying them as such, using the cartoons and humor from the original oil crisis of the 1970's. This is all they really are... anti-free trade, protected by our bought and paid for government cartel.

It goes back to my having John Cleese do a ministry of messing up freetrade and healthcare routine. You couldn't make this more F'ed up if you intentionally tried. Give the large corporate side that naturally has lots of power simply in its wealth and access, an anti-trust waiver while maintaining and very actively enforcing and creating newer and even more restrictive anti-trust laws against the smallest of businesses, small and solo practictioners of healthcare who by their very small business nature have very little leverage in relation to the large corporate interests.

They are such a cartel that even very large employer groups have very little real leverage to negotiate good prices when they offer up thousands of covered lives in exchange for their business. We need to actively say it and paint them as such each and every chance we get... To the strongest cartel in the nation if not the world, the insurance industry which has our government, its enforcement agencies, and the courts in its hip pocket. CARTEL, CARTEL, CARTEL!!!

Good Night and Good Luck,
Paul

Aaahhh Come on folks, nobody even wants to get in on this one???? Let's have at it... Or should I take this silence as a passive form of agreement with my basic position???

Paul:

You need to check out this guy's blog:

http://drhorvitz.blogspot.com/

Here's his main website:

www.DrHorvitz.com

Paul, you'll like this one. Yesterday Anthem sent a representative in to do their routine chart audit (because I refuse to copy or fax charts and send it to them. If they want the info they have to pay someone to come get it. I am not using my staff to do their work). The woman was given a very nice and quiet place to sit and we did pull the charts for her. Once here, she asked if she could use our copy machine to make some copies of charts. She was emphatically told "NO", not unless she reimbursed us $.05/page. First of all, I am not using my ink and paper and machine for them to aquire their data and secondly, her presence in the front office would have made it way too crowded. She huffed a little but completed her audit and left. Now, had I been totally paperless, I wonder how this audit would have transpired. I still would have made them send someone to the office but then would she have tied up one of my computer terminals to aquire the info she needed? And, would I have even trusted her enough to get on my computer and use the software? I don't give them an inch. The harder I can make it on them the better.

Leslie

Leslie:

Worse yet, if you had given them an OK to use your EMR, they could have used it to see how you were actually getting paid by other patients NOT in your plan. They could have searched for evidence of downcoding for cash patients, or to see if you are willing to work for less money from another insurance company.

Even worse is when you have a paperless office and get sued- they can actually subpoena your database to look for practice patterns and use THAT against you.

Cheers,
Al

The CARTEL is cracking... check out these 2 threads that I started at emrupdate:

-- Article: The show will go on - without Cerner, http://www.emrupdate.com/forums/t/13925.aspx
-- Article: Healthcare IT companies may be on GE's shopping list Healthcare IT News, http://www.emrupdate.com/forums/t/13926.aspx

The powers at be at emrupdate did get upset at the bad news (these companies do advertise there), but heck, I'm "fair and balanced" in my reporting. It's just that there is no good news about these EHR companies at this time. I specifically kept my glee to myself and reported the objective statements of the authors.

Excellent points, Al. That may persuade me to keep my papered office.

Leslie

Paul I hope I get to meet you and kick this around in the evening at Branson. I personally think we are right on the eve of massive change for health care in America.
Leslie, you are right to mistrust the insurance industry, but you maybe short sighted if you choose paper to hide from them. The paper is not thick enough to protect you. I am gambling that full transparency is possible, as we build a database we can track our own outcomes and use that data to prove we are doing a superior job. And a superior job should net a superior outcome, and a superior outcome should net a superior PROFIT and I want my share! We are in a 5 year contract, and have put the IPA on notice that we will negotiate a higher rate if we are able to demonstrate the profit. Since the IPA expects to pay us only a percent of the profit, (they get to keep the balance, since they have the risk)they are on board with the project. But the whole concept of a "Medical Home" model of practice and an "Outcome Oriented Medical Record" is impossible to achieve without an EMR, in my opinion.

I still say until they are willing to completely get out of the way, drugs, treatment, prior auths, tests and all the rest you guys are overly glorified employees. They are making some of your most important medical choices or forcing you in a certain direction...

Now they want to hold you accountable for the outcome no less??? BULLCCHIT! And I have yet to hear a good answer to my idea of docs who are paid to see less patients, slow down and ask lots of follow up questions, probe for data that might be useless until years later when something pops up, this is quality. Where was all their concern about quality until they wanted to take your last good dollar? While Henry Ford (facsict pig) was speeding up the assembly line to in-human pace? All I ever see in the Medical Managment Mags (rags???) is "speed up and see more patients. That is the answer to all financial troubles. Bull!

We need to insist on being paid what you folks are really worth, ESPECIALLY the Office Visit! Stop devaluing the office visit, for this is where the rubber meets the road. Let you guys slow down and we'll get all the quality we can handle.

And never forget, what one gets paid for what type of work, no less how and what is measured, is in it's very nature a "Labor Management" issue that should be hammered out via collective bargining, especially when negotiating with an "F'ing" CARTEL!!! I was just talking to Nancy about this thought the other day... Each and everyone one of these CARTELS has their own formulars, their own list of allowed or not allowed treatments, step therapies, P4P measures, billing, payment and bundling policies, and they are all so self-rightous about it all.... Well my question is as follows: If they are all different, how can each and everyone one of them be so "Right"? It's like the religous nuts, only their way to god is right, the rest of us are all going to roast in hell.

Everyone post your clip art from Al anywhere and everywhere you can.... CARTEL, CARTEL, CARTEL!!!!

Paul, I basically agree with you but perhaps not with quite your verbage. Two more examples recently. I have been having very good success using Januvia in many of my diabetic patients. I recognize, as do most diabetic specialists, that diabetes is not a single disease. It derives from several different etiologies and today we have good treatments that address these differences. I almost never use a sulfonylurea any longer, choosing safer and more effective medications. But, try to convince HUMANA that you ARE practicing state-of-the-art medicine and ARE getting good outcomes with Januvia. They refuse to approve it unless you can document that the patient has failed at least 6 months of a sulfonylurea or a thiazolidinedione (for which the FDA has recently required additional CHF risk labeling). Try to tell them this or point to the studies and they still deny it, because plain and simply, they are not responsible for the outcome of the patient!! They are not trained in patient management and they "practice medicine" by protocol. Unfortunately, these protocols are not stagnant. They are constantly changing and the insurance companies do not have the motivation nor the financial or medicolegal incentives to constantly review, update and change. It is in their financial disinterest to revise their old protocols. And these are the entities that are judging my outcomes? PHOOEY!
Second example happened today. I know a patient whose sister recently had two coronary artery stents placed and his other sister (both are under 60 years old) recently had a 4 vessel CABG. Their mother had a massive MI at age 42. Both siblings were told their coronary arteries were "highly calcified...like concrete". Their cardiologist recommended the other siblings be screened for coronary artery calcification. His physician subsequently ordered a cardiac CT but his insurance refused to pay for it because it was still considered experimental. GIVE ME A BREAK!! When is the last time they read a medical journal? This really burns me up because, that man is my brother...I had the stents.
So, I have to agree with Paul. We cannot allow these idiots to tell us how to practice medicine. The courts will do that for us.

Leslie

This is the reason for the boom in micropractices and cash-only practices. Jim Blaine has an on-site clinic that operates on these principles and I believe he plans to talk on this topic at the Users' Conference.

The insurance companies and the government are not going to reform themselves, and we don't have the power to reform them. We can OPT OUT, however, and leave them talking to each other.

We give them power over us when we agree to take their money.

Lets put this in perspective.

Can we have the Doctors in total control without accountability? Evidently not. It was called the "Golden Age of Medicine" and most people had FFS insurance with no restrictions. I remember hearing the story of a local Doctor who didn't want to sell his yacht while his new one was under construction. He used to brag that he financed the entire cost of 50' sailboat by,"ordering more EKG's". You say it wasn't you, I know it wasn't me, but it most certainly was the collective, us.


So we have someone looking over our shoulder, and a perfectly good drug like Januvia comes along. It is VERY expensive. If it wasn't, the insurance would not care one wit if you Rx'ed it or not. They are ONLY dealing with the money. That is their job. The drug has 7 more years of patent. For these seven years they have to stem the flow of red ink. They don't care at all who needs it or who gets it. They only care that it isn't too many people. Silly artificial rules are applied to the decision process and the timid or the disinterested are turned away, you jump through enough hoops and you get the meds for your patient.

Now consider the "Outcome Oriented Medical Record". My IPA can keep track of all the costs that they incur for my patients. I manage the patients following all of the best practices I can bring to bear. I predict that when my numbers are at the top of the game, I will be able to say, "I want Januvia for these X number of patients" and the director of the IPA will say, "Give him what he wants". (Thats my fantasy and I am sticking to it!!)

DocM,
I sorry but I just can't go there. I want to try and find you my old post about, "She Should Have Gone to Cornell" about how if my wife Nancy, an FP would have gone to Cornell School of Vetinary Medicine, Instead of SUNY Upstate how different our lives would be and how different our practice would be. I coached a great, intelligent, hardworking, creative kid, who not only at a somewhat small size was he one of my two best defensemen, but 12 years later, he is married and just about to graduate Cornell. I met him when Nancy was an MS 2 at SUNY.

So where is coach Paul and his wife as compared to this "KID" who is about to be brought under the wing of a good local vet who wants to just about hand him the keys to his practice some day? Who's time and money and efforts were better spent? Why does the vet down the road, who cares for Fido and Whiskers get paid at time of service, full charges that he sets at market rates for better or for worse, while guys like you and my wife have to deal with a legalized CARTEL who continues to increase their profits while they hold flat or reduce your rates based on JUNK science???

Outcome studies from clinical encounters are NEVER even single no less double blind. Both the patient and the doctor know what went down and who got what. How much bias is there in this stuff? Sorry but this kid from Da Bronx was a Pysch major and I learned more stats and experimental model in undergrad then many of you learned thru out all your studies.

Yes outcomes have their place, but what about the mouse chasing his tail just like in the big corporate practices? Do you remember the old anti-drug ad about snorting coke? The guy worked harder to by coke, so he bought more coke so he could work harder, so he had to work harded to buy more coke and the picture showed him zooming 90 degrees to the floor speeding around in a circle? This is productivity medicine. At what point do you reach a point of deminishing returns and become that rat chasing your own tail. At the large ugly corporate pratice Nancy left that was full of productivity, at some point there was nothing you could do, but slack off for a year or two, take the hit, so your numbers could go down, just so you could bring them back up again some time later... That is just insane. How about paying me appropriately for what I really do already?

Do you value it or not??? Just look at the relative value units and you'll see all you need to know. Procedures have great high values while office visits which PCP's live and die by are at the bottom or the heap. Don't get me started on IPA's and PO's that take better care of their specialists than their PCP's who then add insult to this injury with contracts that add an extra 10% to the fee shcedule for procedures as compared to OV's. BULL.

Well, are 50% of all docs bad docs with bad numbers? Somebody has got to be on the other half of the bell curve? What about patient free will to slowly kill themselves, with food, cigarettes, no seatbelts? Will you dismiss patients who don't fall into line and pass them on to the starving more compassionate docs? (Not implying your an SOB, but you get the point?) What about sticking with non-compliant patients and doing the best you can under the conditions at hand? And since when did we become the entire countries "Mother"? "Mrs Jones, I have you an order for a Mammogram (Bloodwork?) and we haven't seen the results and it has been three weeks now, did you go?" How many phonecalls, how many letters, at what point are you at 18 years of age or greater, a grown adult who must step up to the plate and take care of yourself for crying out loud?

We have a patient who is now on the other side of recovery, she now takes care of her family who used to take care of her, she is now the most responsible person in her group. But boy did it take forever to get there. The day we sent the request for her records to join the practice, the other pratice was probably laughing at us, they faxed them back the very same day... No CCHIT. We sent her the bad patient, you have 30 days at least once if not twice, but now here she is on the other side. P4P would have dictated dismissing her the first 3 months she was here, whine and spaced out. Now she has rejoined society and Nancy and I smile everytime we see her. It's like she was given a second lease on life and she knows she owes half of that to Nancy. And I always pump her up and tell her, "well we did show the horse the water, but you did most of the heavy lifting, by looking deep inside, working hard and getting well." They can take P4P put it you know where....

I guess I'm an old hockey coach at heart. Sure there are guys who's numbers are obvious and it is great to have a top scorer, or a guy with tons of assists who set up their teammates, or defensemen with great plus minus ratings, BUT, there are somethings that can't be measured or when you try to measure them in a small perspective, they look like they don't add up, but there are some guys who are bigger and more important than their numbers, those go to guys who are just born leaders, whether with words or by their actions on the ice. You just know you want them in your locker room come playoff time.

I guess what I'm saying in a real round about way is: You can't quantify only by healthcare costs alone the good docs and other providers do and don't do and it is very intentional to keep this agrument small and narrow on costs of care, drugs, verses revenue collected for that care. Because unless we measure the whole cost of lost lives, tax revenue, burdon to the system on the other side in terms on welfar, Medicare, Medicaid, Unemployment, disability, the impact of a disabled bread winner on the entire family and the local economy, they insurance carriers always win.... You just can't quantify what you guys do half the time, you can't prove or disprove what never happened to be measured and it is not on the insurance carriers books half the time anyway.

No less why is it always the docs who get cut, but never the MRI Manufacturers like GE, W-A here in my area, MidMark and all the large Pharmas? Why not control their prices? Half the stuff that Big Pharma has protected, its basic research almost always came from the tax payers with grants? When was the last time GE supplied CAT scans or MRI's at a loss like most of you docs provide your care?

Let good docs be good docs, and we'll get all the quality we will ever need. I still feel she should have gone to Cornell....

Good Night and Good Luck.....
Paul

>>> We give them power over us when we agree to take their money.

Actually, that's not entirely true, although I wish it were.

Medical Economics just ran a story about what Massachusetts has done- put out a law that will force all practitioners to have a CCHIT certified EHR by 2015 as a prerequisite of getting your license: http://medicaleconomics.modernmedicine.com/memag/Health+Information+Technology%3A+Electronic+Health+Records+%28EHRs%29+%2F+Electronic+Medical+Records+%28EMRs%29/EHRs-Another-state-goes-down-the-mandate-road/ArticleStandard/Article/detail/508520
So there may not be anywhere to hide from something like this or from a Hillary Clinton everyone-is-covered socialized medicine scheme.

We're royally scr****... Veterinary medicine anyone?

I read the article. Lawmakers would like to ensnare physicians in this net, but it is by no means clear that they will. Seven years from now. In another state. The question is, how am I going to live and practice in the meantime?

Here's what the article said:

(By the way, what the heck does that all mean, exactly? Who wrote this passive-voice, ambiguous mishmash? Is this the result of poor writing skills, or an attempt at "spin"?)

Ptui. If those Massachusetts lawmakers are that boneheaded, and their physicians are too spineless to stand up to it, then they deserve what they get.

The new Massachusetts Miracle will consist of decimating the field of physicians, and enslaving them to an inefficient EMR that kills their productivity, leaving Massachusetts helpless against the onslaught of aging Baby Boomers.

The winners will be the providers of expensive CCHIT-certified EMRs, which will drain the state health-care coffers, gambled away in the pursuit of that elusive ROI....

Meanwhile, all the smart doctors will leave for greener pastures. Come to Arkansas! We need more doctors!

Brian and gang,
Unfortunately Mass is in the middle of a perfect storm... Where are some of the most respected Medical Schools, Residency Programs, and Hospitals, Boston and surrounging Mass. But where is the homebase of the insurance industry, where did they get their start, Same place. When combined with a well intentioned, misguided, ill-informed do good politics you get "The Perfect Storm". If all those docs, and there are a ton in Mass, ask Jon, can not stand up to these SOB's then we are all in for a rought ride, get in, shut up and buckle up everybody.

I just wasted (did I really?) most of my bookkeeping night researching my AC database (sure wish it had more PM features) to see how many PIFATOS (thats Pay in Full at Time of Service)patients we have, how many non-par patients, how many still have some amount of freedom to not be trapped in network only ala HMO and POS, but instead have things like traditional indemnity and PPO type plans. I am just about ready to cut off my nose dispite my face as my dad used to say, and finally take that scarry leap into, Cash Only, PIFATOS, with a modest membership fee in exchange for some what reduced fees. Plus, Psych is still mostly cash and carry here, and Nancy does a good deal of it already with so many of our patients, that we might as well give in and see if we can't make it. All while still providing primary care for those who want it... As long as they pay, right?

These CARTEL SOB's have gone too far when they start wasting an hour or two (really no CCHIT) of my staff and my DOC too, just to get a simple CAT scan or MRI approved. And if we starve the new Bush based Bankrupcy laws will make sure I have lots of company in the new debtors prison. I sort of feel like that old coal miner song.... "ya haul 16 tons and whadda get? Another day older and deeper in debt, (there is a line right here I can remeber now), I owe my soul to company store...."

I just can't believe my own eyes everyday anymore, it is just so out of balance and one sided that you just can't make this stuff up. "Well here at the ministry of screwing up free trade and healthcare to all bloody hell...." Jon Cleese where are you??? I've gotta go because I need to take care of my poor wife tomorrow as she has minor oral surgery... Have a great weekend everyone....

Good Night and Good Luck,
Paul

"and most people had FFS insurance with no restrictions. I remember hearing the story of a local Doctor who didn't want to sell his yacht while his new one was under construction. He used to brag that he financed the entire cost of 50' sailboat by,"ordering more EKG's".

And now days, how many people who really should have EKGs are not getting them because the reimbursement does not cover the expense? Which is worse? Which is healthiest for the patient? Which kind of physician would you rather treat you? When the practice of medicine can be practiced by protocol alone medical degrees will no longer be necessary. Take it from an ex-physician's assistant. I treated tons of patients in the 70's by simply running my finger down a standard protocol and doing what it told me to do. I had no idea why I was doing it or what other options there might be but, by God, if it was in the protocol it was right. Then I woke up. I became curious. I wanted to know why I was doing things. I went to medical school and I learned the ART of medicine. With no offense intended, DocMartin, I cannot help but believe your proposed Outcome Oriented Medicine platform will bring the end to the practice of medicine as we know it today. And it will devastate the profession. And, in the end, the people will be no better cared for. The money will simply be shifted to corporate entities rather than to the people actually doing the work. Then all the insurance company stockholders can build their own yachts while the "providers" (whoever they may be) can punch the clock, put on their stethoscopes, manage the assembly line of patients and wait for the afternoon whistle to blow so they can stop down at Kelleys on their way home for a brewski.
Sorry, I am with Paul on this.

Leslie

Paul makes some excellent points, especially regarding how we protect the patient who is determined to be an "outlier" with frequent ER visits for a cold or runny nose etc.
And Leslie I take no offense whatsoever at your criticism of my "Outcome Oriented Medical Record". I appreciate the time you are taking to give me the feedback as I work to define this concept.

But let me separate this into three parts.

1- The "Medical Home" model of practice as pioneered by pediatrics for the past 20 years is a valuable concept that all primary care physicians need to embrace and expand. It has nothing to do with the money, it is just a comprehensive approach to medical care and management of the records. (And it was never any invention of mine, the AOA adopted it several years after the AAFP and I didn't catch on for two MORE years!)

2- My idea of the concept of an "Outcome Oriented Medical Record" is an approach to the management of the patient and the application of this powerful tool that the EMR provides. The concept of practicing medicine on your practice, the database, that is what I am most excited about. If you were to embrace this concept, returning to your database to practice medicine on it, (the database) think of the power it gives you. You return from a conference with knowledge of a new treatment for condition common in your practice. Turn to the database to find the appropriate patients. Contact them and notify them of the change in therapy without waiting for them to show up in the office on the next appointment, if they keep the appointment. Paul you are upset at the adult who does not take responsibility for following up with the orders for a mammogram or lab work. But it still needs to be done. And what if all the call backs for failed follow thru on mammograms or labwork were only one keystroke of your EMR. Then why not help them? Would you refuse just because they are adults? Of course not. NOW WHAT IF the EMR could keep track and anyone who failed two tasks could be identified and the EMR cues them up to come in for a MMSE. Do you see what I mean. You have the same relationship with the patients but you also have a relationship with the database, and you return to it time and time again to build it into a healthier PRACTICE.

3- In a managed care environment I think that I see a way to get paid for the extra work if we negotiate our rates based on our outcomes, but that is not really relevant if you don't have to deal with a lot of managed care.

I have absolutely no problems with using the database to identify patients that may benefit from "new" concepts. I do this all the time already. In fact, I have been using my EMR for the last 9 years not only to replace a transcription service, but have used it because it provides a searchable database. When Bextra and Vioxx were recalled it took me only a matter of minutes to bring up and call all of my patients who were on them. I routinely identify all diabetics or hypertensives who have not been seen in the office in 6 months or more. Every 6 months I also run a list of all patients who have not been seen in over a year. I can then call those that need follow-p appointments (should they not have already been caught by my PM program's reminder feature).

I do however have serious concerns about insurance companies and other third parties using my database to determine whether I should be paid at a 3rd tier level or a 1st tier level. And, give them an inch and they will take a mile. I have been in medicine long enough to know that insurance companies will not negotiate with you no matter how efficient or wonderful a provider you are. They may let you BELIEVE you have negotiating power but, just the fact you are HAVING to negotiate already gives them the upper hand. Why should you HAVE TO negotiate for fair pay? EXAMPLE: I regularly discuss the importance of patients over 60 being immunized for shingles. I spend a lot of time explaining this to patients. That is good medicine. Humana however will not pay for this unless I administer the vaccine in my office. I have asked until I am blue in the face for Humana to provide me with their reimbursement schedule for the purchasing and the administration of this vaccine in my office ( as a solo practitioner, I cannot afford not to at least break even should I elect to do this for my Humana patients). After almost 6 months of calling, emailing, writing letters and having patients with Humana call I have yet to be given ANY reassurance from them that they will cover my expenses. The only reply patients get is that "the Zostavax is a covered procedure" which simply means the patient will not have to pay anything out of pocket. It does not mean I will be fairly paid. Subsequently, none of my Humana patients have been immunized...that is bad medicine. You CANNOT tie your
care for your patients to what a third party payor is willing to pay for that care!!! Please, it is not a realistic endeavor. Certainly in this day and age we as physicians have a duty to provide quality care and do it as efficiently as possible. But, no matter how efficient we may want to be in order to "please" the payors, we still have that patient with their goofy symptoms or the headache that won't go away as well as the lawyers leaning over our shoulders...Humana does not. Being an "efficient doctor" on paper (or your database) does not mean squat when you are sitting in that courtroom or when you have to tell a parent that, golly, their daughter's headache is being caused by a metastatic melanoma which now is too advanced for treatment. Juries and patients have no concept of "the statistics did not support a decision to get an MRI" or "the patient's insurance company refused to approve the procedure". I don't know about you, but I take it personally when I miss a diagnosis or a patient transfers records because they felt like I did not take enough time to listen to them. Damn the insurance companies! I am sure my stats suck when compared to yours. But I'll put my ability to diagnose and treat and produce a good patient outcome up to yours any day.

Leslie who again hopes no offense was taken by anyone.

Leslie
I think you are right on the mark with your comments on the insurance companies and your reticence to trust them. Their behavior is abhorrent and borders on criminal in many cases. It is typical that they will not publish a fee schedule, they let you take the risk, and let you know after the fact, what they will pay.

I am sure my numbers stink, except with respect to my high use of generic medications. My immediate goal is to use the power of this system to make me a better Doctor. I believe the cost savings will come directly with best practices AND with diligent collection of data to reduce duplication of efforts.


A solo practitioner is David and Goliath without the slingshot. You don't stand a chance against any insurance company, not even Medicare which is the least criminal.

Do you have "managed care" in your area in the same form that I do? That is, I belong to an Independant Physician Association (IPA) and it is the IPA that has contracts and negotiates with the insurance companies. The IPA sets the rate that will be reimbursed for the vaccine, and I know the amount up front. If one carrier, (Humana for example) won't pay well enough the IPA has the option of shifting business away from the plan. It is the IPA that has an army of marketing folks who go door to door preying on the elderly, No strike that, who go door to door helping the elderly to select the best insurance product for their needs. They will move away from a carrier that doesn't reimburse well enough to cover costs. It is the IPA that I believe I will be able to negotiate with. If I do have the quality of practice and good outcomes, that are also cheap enough, and I find the IPA is not willing to reward this effort then I will walk. There are at least 8 IPA's in my immediate area. It is my understanding that HMO insurance has not made anywhere near the impact in the midwest that we suffer here on the coast.

Leslie I forgot to agree specifically about not letting anyone else have access to this database. It has real, significant value, and preventing the insurance industry or the government from gaining access to the database should be a very high priority for all doctors. But denying someone else access is not enough. We have to find ways to be reimbursed for the value we have created in the production of the database. We don't want to just sell the access either. NO ONE should have access to our patients private records. But that DOES NOT in my opinion exclude the physician from turning to the database to try to build a better and yes, more profitable practice. No one can afford to work for free. Thank you again for listening.

DocMartin (I would sure like to be able to call you by your given name),

I was in medicine BEFORE managed care was first conceived and I have been around to see it devour the profession and then spit it back up. I have, in the past, belonged to a physician's group whose mission was to give docs bargaining power over third party payors. In order to finance this project, we all gave up 2% of our remimbursements from the contracted companies. Unfortunately, this group had absolutely no more bargaining strength than did I standing alone. When I became tired of giving up 2% for nothing, I dropped out. My individual contracts with those same companies did not change one bit!!! The only difference is that I now get to keep my 2%. The IPA subsequently faltered and died because of it's lack of showing progress. Have you ever called your insurance company to ask what your contract details would be if you were to contract individaully rather than through your IPA? In my opinion, these IPAs do not do any more for the individual physician than do our professional societies (AMA, AAFP). Big talk, no action.

We physicians accomplished more individually by whispering (because we legally cannot talk about it with each other) our dissatisfaction with certain insurance company practices (such as Aetna's "all-or-none" policy) and simply stopped seeing those patients. We essentially drove Aetna out. Only after they dropped that distasteful policy did we again begin seeing their patients.

The same is now occuring in my local market with United Health Care. This subsequently puts pressure on the patients to negotiate with their Departments of Human Resources to offer plans which are taken by their physicians. It is slow going, but it has shown success. When a whole community of physicians "just by coincindence" opts out of a major plan employers are forced to look at other plans. The purchaser of the plan has much more influence over the plan provisions than does the provider. That's why even one physician who is willing to bend over for the insurance companies can bode disaster for the rest. We must stand firm in our commitments to the profession and the patients. Producing good outcomes is vital to that notion but not because it pleases the insurance company but because it is fiscally and ethically the only acceptable thing to do.

Leslie

Leslie, forgive my 'anonymity', I fixed it.
I absolutely agree with everyone following most fair contracts and slowly pushing the payers into line. It is slow, but the only option on the FFS or PPO plans that we deal with. I have also watched the evolution of managed care, at least in my own little corner of the world.

Of course I wasn't in practice yet when Kaiser began to care for the families of the employees working on the Hoover Dam, (actually I wasn't born until 1949) but I was in practice for several years before the first small IPA opened at my hospital. I joined it eventually, and suffered all of the layers of idiotic paper work and bureaucracy that has marked the early days of managed care. And I have fought with and traded insults with hospitalists for 15 years. But I see this very differently now. Especially because our patients are voting with their feet. If they are very wealthy, they stay with Medicare and a supplement. But the overwhelming majority have chosen to have health care provided by an HMO.

In our situation the IPA does hold the risk contract with the 3'rd party. In some networks there is also a risk contract with the hospital. In others the hospital contracts with the IPA to provide care at a given rate. There is no way for the individual doctor to contract with the 3'rd party directly. From your comments I take it we are not engaged in the same type of practice as you. In this, "capitated" system I am paid a rate which might range from $35.00 to $80.00 per member per month in the case of Medicare patients. For that capitated amount I agree to provide all the contracted, office based care that is required. I can do an EKG every year without trying to find an excuse to justify it. I can also do an EKG every day. But I get paid the same capitated amount. I find this style of practice to be very liberating. I can concentrate on the patients, the money, for the most part, takes care of itself. It is of course much more complicated with the IPA re-imburseing us for flu vaccine and paying little extras like a small fee for excision of a skin cancer or a small fee for providing well woman exams. The reason that we are paid extra for those items is to accommodate the patient who selects our services, (and to encourage us to provide it) and still financially manage the costs of the patient who selects her gynecologist for the annual exam.

Sorry to make this so long, but my point is that the IPA clearly has the ability, especially when combined with the hospitals risk contract, to negotiate. We have twice recently been in a position where we could not admit Blue Shield patients to one of the local hospitals while they slugged it out.

And I clearly have the ability to negotiate with the IPA. We have, and do engage in negotiations. What I am excited about is using the combined power of the IPA and my practice to seek best practices and cost savings. The biggest single cost saving that I expect to capitalize on is a zealous effort to gather records, and make the records available, thereby reducing duplicate testing by hospitalists and consultants.

And finally, some encouragement. The system does learn and get smarter. 20 years ago we had to get permission for a patient to get a mammogram. The layers of paper work guaranteed that some mammograms would be denied because of some paperwork inadequacies. Eventually the IPA's figured out that no one was profiting from doing excess Mammograms and the patients themselves were not inclined to submit to mammograms unnecessarily and so the 'approval' became automatic, you just refer to the contracted facility. It has continued to get better. Currently about 80 to 90 percent of referrals are obtained online at the time of the patients visit. They have the approval and the appointment before they leave our office. (And by the way, we get the capitation check every month, right on time without worrying about 'clean claims' or submitting 'more documentation')

Martin,
Since when did a provider of healthcare services become an insurance carrier or a partner there of??? Since when did we get put in the roll of covering and insuring lives? Is this not the ultimate form of anti-free trade? Why should you provide extra visits for follow-up to anything? The less care provided the lower your costs except for those mentioned procedures?

We should never have to let the HMO withhold our money, we are not in the business of assuming "risk" as an extention of the carriers, we are the provider of end care services... Which in many states if we just fought hard enough would get many of you guys declared as "employees"!!! One day when I have some extra time (ya right...) I'm going to post the 20 things that the IRS uses to determine if someone is a private contractor or an employee and I'll tell ya right now, you guys could easily fall under either catagory. All it would take is the right person who's family member is a doc to finally tip the scales.

But even if you are all still private contractors, since when except in the CARTEL situation, would any two parties enter into a binding contract, before all the actual numbers, the fees, the costs and all the rest where clearly knocked around, and written down? Nobody else is asked, pardon me "TOLD" drafted, forced to work, actually enter into a binding contract without first knowing clearly how much are they being paid for what clearly defined services or work. This is a simple matter of what all other business relationships are all about. Only in 3rd party health insurance situations does one not know what they are going to get paid for whatever services the render, supplies they consume and use on behalf of the other party, or the work that they have done. THIS IS JUST INSANE! It's like I've been trapped in some acid trip, down the rabbit hole nightmare for four years now.

And to all of you who had the pleasure and the opportunity to at least stash away some money and resources for your kids and retirement before the entire system went to hell, try to imagine me and my Nancy, and Dr Vinny who never had that opportunity, as we try to simply survive on this insane, inhuman system. We can't pay down our debt, we can't save a dime for us or our kids, we can't afford a new car (which rust out here pretty fast, new cars are a CNY, rust belt requirement) or to fix our roof or fence, no less replace our leaky windows. This is just insane and inside out. Something has to give.

I never promised anyone to assume any of their healthcare risks and I feel it is totally insane and inappropriate to ask that any of us do. They carrier is the one selling the idea that if given a certain amount of money, they can managed and assume the risk, so they sign up employers to pay in exchange for them assuming this risk. You are "F'ing" doctors, not insurance brokers! "Damn it Jim, I'm a doctor not a stone masion." (sorry I couldn't resist)

Imagine having to assume motor vehicle repair (mechanical warrentee) or accident risk (actual motor vehicle insurance) for motorists, just so you could repair their cars whether as their regular mechanic or the autobody repair guy??? Where is this IPA, HMO or any other form of widthhold or assuming of the risk any different??? we should assume risk because we did the brake job? They may have fewer accidents with better brakes??? BULLCCHIT!

They insure the patients, we should charge what the market will allow, they can pay whatever they are willing to pay, and the patient pays the rest. And just like the guy who did Nancy's oral surgury yesterday, we PIFATOS way over a grand mind you, VISA in hand. Sure as a courtousy they submitted a claim on our behalf, but they don't PAR, the carrier will hopefully pay about 50% and so when all is said and done, we will still have paid $600-$700 bucks of this guys $1300 charge.

But now that the docs who came before guys like my wife and Vinny let this camel stick his head in the tent, now we are all stuck sleeping with it in our beds. I just want to say a really big thank-you for my falling down roof and fence, my kids not going to a decent college (at least not paid for with help from mom and day, it's state university all the way for our kids...), and last but certainly not least, my having to compete on line with 25 year old kids to buy my "new" 10 year old Jeep to replace the older of our two daily drivers.... Thanks guys, really we couldn't have done it without you. And thanks for never taking the time to go to talk to pre-med students and never warning them NOT TO GO INTO MEDICINE, NO LESS PRIMARY CARE!!! I think there should be a class action suit against all primnary care residency programs and med schools for leading this new group of sheep down the road to ruin. What a load of horseCCHIT.

Well, the IT team here needs to get some serious work done around here, so let me go. Oh that's right we can't afford an IT team, I am the IT team... How sad is that????

Good Night and Good Luck,
Paul