Home Forums Discussions Feedback and Recommendations Pay For Performance

I wonder any body in the AC community is getting a bonus from CMS thro' the P4P program. Last year, I thought 1.5% bonus of Medicare and Medicaid collection offered by P4P is not worth the trouble and pain in documentation. The more I read about it, the more I worry. CMS is trying to cut expenses. P4P is giving bonus in the beginning, the real intention is cutting reimbursement down the road. Physicians/hospitals/practices that do not submit P4P probably will face a bigger cut in the future. That's why all the hospitals are rushing to have "medication reconciliation forms" all of a sudden.
As of year 2008, I can easily pick 3-4 "Measures" out of the 150 "Measures" set for P4P. Overall, P4P just requires the additional sub-code to be sent in with the billing. Can AC add the sub-codes to help documentation of the Measures as we sign the charts for billing?

Not yet but this is a topic for the discussion in Branson. Amazing Charts (and everyone with or without an EMR) is going to have to deal with this and very very soon. I had the privilege of talking with Jonathan Thurs and today (at the Pri-Med West conference)and it sounds like he has two goals. One is to do the job for P4P. The second part is to do it in a way that will allow the flexibility to be ready for the next thing they may throw at us AND to be able to add things of our own, (individually) as we identify the strategies that will allow us to really practice better medicine. (This is what I keep calling the "Outcome Oriented Medical Record", and yes I bugged Jonathan about it, and he was very polite and attentive.)

Martin,
I know and trust in my heart that your interests in how to better use computers for the betterment of your practice and more importantly your patients that you so obviously care about a great deal (and good for you!) is very sincere and seems to be almost a passion now.

But I am concerned that these kinds of features will be like nuclear science. Sure it has some good to offer mankind, but once this genie is out of the bottle there will be no stopping our FISA court government and thier CCHIT minded friends who are paid hansomely by the carriers to allow all these negative players to come feast at this table.

As always man's technology is far out pacing his ability to control and us it wisely. This is such a case. I feel and I'd love to hear other people's input here, that perhaps what DocM seeks here, it is not evil, just as TV is not junk or Evil, it is how we choose to use it that makes it good or evil.

So what I would love to see all the players involved do, and I think to some extent we have all been saying in one way or another is; that if and until we really have it out, and make the guiding principles and the ethical rules first, first we hash this so important issue out, then and only then will we allow it to move forward. Much like cloning. I mean if our civil liberties and medical privacy are not nearly as important as something like how to use and control cloning then perhaps we don't really live in American anymore. This I feel is what all those bozos at the AMA and other societies should really be howling about...

The technolgy should not be allowed to fall into the wrond hands to be used by special interests for their own selfish and vested interests. It should only be allowed to be used for the real purpose of medicine, and nothing else.

Furthermore, rule two, just like any other research project, informed consent for all patients with no penalty for opting out. Same for all providers. One should not be forced to particpate in the world's largest on going research study just to access their healthcare provider or have whatever form of insurance pay for it, right? Patients who care to passionately can pick another provider who does PAR with the project, perhaps like Martin's. Those who care about their privacy and care to opt out may come to a practice like ours instead. Informed consent, totally penalty free right to opt out, what is so wrong with any of this? We have always insisted upon it, so why not here on this the most invassive project of it's kind ever conceived and proposed?

It is my belief that unless they force it down our throats they know that most if not all providers and citizens would opt out at least in terms of data submission to "the project" and the spies. And so they make it mandatory and force it upon all of us.

Like here in NYS with the Vaccine Regisitry they made the opt out age 19 instead of 18 so as to capture most young adults, because most of them need one last CPE and at least the Menigitis vaccine to be allowed to go to college. How many of these smart well intended kids are going to postpone going to college an entire year especially with scholarships and other finacial aid sitting there, no less the competitve nature of just getting into the school of one's choice these days, just so as to avoid getting caught in this slippery slope towards their data enslavement to big brother and the anti-trust, cartel carriers??? Right probably almost none of them? Just like regisitring with selective service at 18. Heck they don't even understand half the issues involved here.

What say all of you???

P4P is the next greatest scam created by the insurance industry to figure on how to pay us less, not more. Sure, they lure us in saying they won't cut our reimbursement but they'll pay us more money if we meet certain "quality standards."

I will guarantee this is the hook to get us in. Who are they kidding? Hello? They've been cutting reimbursements EVERY YEAR.

So P4P will turn into a way to desparately cling to declining reimbursements.

Heck Medicare will cut us by just over 10% effective this July 1st, unless Congress intervenes again. Yet P4P in Medicare earns us only 1.5% increase. So we only lose 8.5%, instead of 10%. Gee, that math makes a lot of sense to me <<SARCASM>>.

Some of the private insurers we can reasonably meet the reporting requirements of their plans. Medicare is ridiculous however. The coding requirements essentially demand that we take a course in their new codes to report our "quality measures."

P4P will hasten the fall of the insurance industry.....let's see how this plays out.

On the other side, when I received a $3,000 check from Mainecare out of the blue for P4P, I didn't throw it away.

And neither do we with the one decent carrier that we PAR with that does a small form of this. They simply track claims submitted for the PAPS, Vaccines, Well Visits, and the like. But we do little to get it. But even they have some weird coding stuff that this E&M then goes with the ICD-9 but that isn't how you would code it frequently other than for them.

And that is one of the maddening things. Whether is is regular claims or this CCHIT, it and every one of these SOB's has their own way of doing it, coding it and all the other variables. Who the hell is going to remember and catch all this CCHIT? Aetna this way, BC/BS the other while the gov't some other still. None of the bastards defere to the real proper coding, best care guidelines. It's their own set of codes and things because their bean counters figured out that jumping thru these hoops will tie you up the most so there is the least amount of exposure to actually having to pay you. ANd because of the anti-trust waiver we know they talk among themselves and certainly seem to make sure that one program doesn't really match another, so as to keep you all confused as to have to "properly" (I use that word very lightly) code it for your own saftey no less the best payment.

How about just paying you guys in primary care at 50% better, you all slow down and can not see more than like 15 patients a day so you can actually have real conversations with them, ask extra leading questions, collect info that may not even be come into play for two years, until something new pops up and that light bulb goes off in your head and you go, "ah ha! she told me that she likes to vaction in...... And there is a high incidence of these microbes down there, so she must have....."

Just how much did MaineCare under pay you for each and every code, for each and every visit each and every day my good friend??? As Leslie and I were bitching about over her now doing the meds in office, as she put it so well, "isn't it a shame that in these times docs have to come up with schticks like this just to make ends meet???" Isn't it just???

Everybody wants but nobody wants to pick up the tab or deal with the pain of the underlying cause... "The entire Medical Industrial Complex" and we my dear friends are like poor Mongo.... "Mongo just pawn in game of life".

Good Night and Good Luck,
Paul

Bert,
That $3,000 check was a gift from God.
I hope you get another, sincerely, not speaking sarcastically.
I haven't even closed all of our 2005 Mainecare accounts.
We've resubmitted those claims a dozen times, and each time they tell us, submit it again. WTF?

Adam I may have been misleading if I didn't make it clear that I am TOTALLY in agreement that P4P= less pay. NO QUESTION. But I also think it is a grand piano falling on the coyotes head. I can't stop it. Phase two will be how can I use it? The framework, however poorly executed in these initial forays may still offer us a TOOL for the practice of real medicine. I also believe in my little corner of the world, that if I can generate good OUTCOMES, (P4P criteria be damned, I mean the total outcome) then I can get my IPA to pay me a higher CAP rate. That doesn't help any of you that don't have the managed care we have in Calif. But it might help us all practice better medicine and it might pay you better at some point down the road.

Martin,
You are a voice of reason in this bullsh*t rave called P4P.
You were not misleading. I was just getting a little "upity," which does nothing to help, except makes me feel better

DocM,
What about the doc who takes care of the difficult patients? At least 50% of you will by the numbers have to be below some sort of a bell curve too. But my biggest issue is that at some point let's just say you guys do actually tighten things up and outcomes do improve, at what point do you all become monkeys chasing your own tails for ever deminishing rewards and improvements in the results. Once started these guys will just continue to tighten the noose until you are dead for they are a for profit driven entity that has no regard for you, your practice or the actual outcomes in their patients lives and health, oh your patients, their "members".

Using an EMR as the tool it could one day be is one thing, improving outcomes is a great and worthy goal, but to have 50 different carriers giving you 50 different policies and sets of goals to monitor and report on is just insane. And I as an American citizen still retain my right to not be a data point in some on going nationwide research project. I want to and insist in my right to informed consent and to opt out. No less the right of any provider to be able to safely and without penalty to opt out of such studies too.

"Wile "E" we need to fight this wascally wabbit, ha, ha, ha, ha, ha...." http://looneytunes.warnerbros.com/web/toons/toons.jsp
www.looneytunes.com

I may be either naive, or missing the point... but it seems this P4P is really just Pay 4 Reporting and if a tool like AC can automate the reporting so that it's less of a burden but improves physician reimbursement, well, we want that tool (but we don't kid ourselves that it really improves the quality of our care).

It's never improve, it's about just getting back to what you should have recieved all along. So reporting less than perfect and in the different ways each program and carrier wants is just any easy new way to allow them to take away your money.

My Goodness, doesn't anybody see this for what it really is??? Sorry for all the flames but all this P4P, let's just get in line for our own screwing is driving me crazy and making my head explode! "Hey buddy to you know where the line to the slaughter house is? I want to get in line... " Do you really think these carriers really have patient outcomes and higher payments to folks like you as their real end goal??? Please you folks should be more analytical thinkers than all this. This is just bull, smoke and mirrors, and a great cover story. I mean how can you say no to performance??? Are you hiding something? Are you just rushing, lazy? It's nothing more than Orwellian new speak for making you jump thru more hoops so anytime your paperwork is less than perfect, BANG, there goes 20% of all your fees for every payment for those products or carrier. You will all be sheep led to slaughter... Please get off the line, please protect yourselves and fight back with all your might and intellectual skills.

It's all bull. They have already done tons of studies and math that make sure they are going to pay a whole lot less with these systems in place. And that is above and beyond the added expense of running these new programs. So just imagine how much they are already damn sure they are going to never have to pay you from now on under their new programs.

And just like their formulars, the bundling, their its a covered service under the plan to the members but some how they don't pay you for the service (only in the game of insurance, Simply Amazing) they will continue to move the goalposts, change the spot of the ball and keep you lossing yardage and payments, once in place they will make it worse and worse as time goes by. And do you have any control over these terms?

When was the last time you got them to give you a signifcant give back and increase? Actually sit down and have a fair and level across the table negotiation over terms, conditions or fees???? What make any of you really think that this CCHIT is going to be any different. It is just their next creative game to screw you all real good... Mark my words. Anybody care to make a friendly wager on the this as to whether most docs thrive or starve under these new games??? I'll gladly take that sucker bet...

And if everyone just gets in line and cooperates with it then a majority of you are going to loose. This is the Healthcare version of a big Casino. First off, it is illegal for us to use general skills and math and count the cards (have access to all the data they do for setting and control fees and prices so we can have half a chance to have data to fight back with) and the house always wins. I repeat, the house always wins.

Instead of wasting time and energy worrying about it and then waste too much money thru your vendors and staff setting it all up and doing it all; instead do something useful and in your own self interest, and stand up to these SOB's and start telling them that you already know the truth and that you refuse to be a party to your own next HMO scam type screwing.

"THE HOUSE ALWAYS WINS!!!" You can take your P4P and shove it..... You know where! I know the truth and your lies are showing...

Good Night and Good Luck,
Paul

Read the latest Medical Economics. There is an article there where an M.D. began prescribing more generics to assist with the financial burdens of her patients. Because they could get them cheaper at Wal-Mart than through their insurance drug program, that's where they went. Subsequently, these patients and their drugs did not show up on their insurance companies master lists and, when the companies looked then at the precribing habits of this particular doc, she was rated as being an over-prescriber of brand name drugs!! She was given a low-rating by the insurance company!! I see only problems such as this when we provide any information to the insurance companies which does not directly relate to their ability to pay a patient's claim. That's what they are for...to pay for the claim...not manage the medical care. I continue to play as hard-ball as I can with them. Last week I had a request from UHC for info regarding pre-existing disease in a patient. I completed the form but the number to which it was to be faxed was long-distance. There was a toll-free number to call for questions so I had one of the girls call them and tell them we would be happy to fax back the form when they provided us with a toll-free number. They have yet to do so and have requested the report 3 more times with us giving them the same response. We finally called the patient and told her she needed to pick up the form and either fax it herself or mail it to them but I was not going to pay even $.30 to complete their insurance company's ridiculous request. Granted, I spent a lot of employee time messing with this but it is a matter of principle. The patient picked it up yesterday and said she was calling the company to complain to them. Don't give 'em an inch.

Leslie

It never occurred to me about the windmills, but the donkey should have been a clue. That was a great article Leslie, and I have to share, about 20 years ago I had a friend who was a patient and he applied for some kind of insurance policy. (life or disablility) and listed me as his Dr. I got the forms to fill out, (you know the ones, twenty pages of twenty questions all about his history with me) I cautioned him that his back pain might be something he shouldn't have stirred up so he withdrew, (albeit informally) his permission for me to respond. I got three letters which I ignored. Then my partner got a letter, " Dear Dr. Scott, We notice you have the same address as Dr. Sechrist. He has repeatedly failed to respond to our request to help his patient complete this insurance application and we wonder IF YOU HAVE ACCESS TO HIS RECORDS AND COULD FORWARD COPIES OF THE CHART! Nice.

But there is two sides to this argument. With AC we have our OWN database. In our very own office today my partner was informed that he had not done well on an audit, his patients have too many referrals for the rating of how sick they are. He selected two names he recognized, opened the record in AC and could instantly show what the diagnosis were in the record, and that the auditor had failed to do an adequate job. He sent them packing. It was great. We have the data!

You can hide under the bed, but they are still coming for us. With AC and the proper use of the database you are armed with a big stick. Life is good again.

You know I repect you, but I feel passionately almost like should you kill Hitler before he got too powerful and out of control, that sometimes you need to cut certain things off at the knees instead of trying to minimize the damage for the impending storm.

Sometimes people of good conscience need to be willing to be hurt, put themselves in harms way, and take a stand or otherwise you will almost certainly be over run, invaded and taken over. I see this along with the total access CCHIT styled E medical record as one of those important times in history and one day we will all be judged as to where we did or did not take a stand on these important issues of civil liberties and protection of medicine for patients and doctors.

Just Imagine if people would of had, bigger debates and longer stop and think periods, resisted passionately HMO's and Managed Care, just imagine where we just might be already. The road to hell is not only paved with good intentions (like yours) but it is also paved with the smoke and mirrors, now you see 'em and now ya don't, BullCCHIT from people like those in gov't and the insurance industry are trying to pass on us today with P4P. Just imagine a medicial world without HMO's, forced selection of PCP's, no policies with only in network coverage, and all their other little games, imagine what that world and business model might look it.

Personally I want to shoot the folks from the 80's and 90's who didn't see this one coming and left those of us who are first getting in today with no saftey net or nest eggs to fall back on; for not looking out for not just themselves but for the future of all doctors and patients and the future of medicine in general.

This is just the next piece of garbage in a long list of garbage that they have created, given a good cover story to, that actually servers nobody but their own greedy self interests, and shame on anyone who falls for it, doesn't see it for what it really is, or stands idle in the face of such obvious bull and allows it to over run us all. Please don't be "co-opted" here with false visions of fighting them by their rules in their rink, officiated by their bought and paid for biased officials. YOU WILL CERTIANLY LOOSE!

I still feel like in the words of good old Jean Luke: "The line in the sand must be drawn here!" And shame of those who knew better or simply kept their heads in the sand... Sometimes one needs to know when it is time to stand and fight. These are such times....

Paul

You simply were not practicing in the 80's or 90's. In 1987 I had a couple come into my office with the grateful wife clutching a purse like it was her life savings. It was her first post op visit, s/p Chole, (Open, no lap chole yet). I assisted, fee is 25% of the surgeons. Medicare paid 70% of the allowed charges, but as I wasn't yet accepting Medicare they were on the hook for the whole fee. If I reduced the fee I feared an audit by Medicare that would reveal I didn't really charge what I said I did. So I sat in my office and watched as this elderly couple counted out nearly $800.00 in 10's and 20's which were clearly close to their lifes savings. (Having been to their home for house calls I know they didn't "live fancy"). It staggers the imagination to consider what this scene looked like at the surgeons, although he did take Medicare assignment. Of course I signed up to be a 'Participating physician' the very next year. Similar events preceded my entry into managed care. My current attitude which is a near embrace of managed care has evolved as I stood side by side with my patients trying to figure out how I could find insurance that I could afford for my own family. Anyone who is not concerned about the plight of patients who are trying to pay the enormous cost of health insurance should probably not be practicing medicine.

Paul I hope you understand that I hate the insurance and pharmaceutical companies. But we need them. And so we are stuck with them. People CANNOT risk going uninsured, (although more than 50 million do). In my area there are enough Doctors and patients that a competing idea could be tried out. (First was Kaiser). Some patients are forced to chose between no insurance and the cheapest alternative. That has been HMO coverage. When people got HMO coverage and it was adequate, there friends and neighbors began to question why they should put up with the high prices they were paying for coverage that didn't seem much different. So the patients switched to HMO's. They switched in droves. The doctors who were brave and drew a line in the sand,... were forced to retire. The rest of us accepted HMO patients so we could survive. You will do the same thing when the HMO penetrates your market. Doctors who have come to understand how the HMO system works have made very comfortable livings. It is certainly a system that needs to be overhauled, but it is the system we currently have.

Practicing 10 minutes from Louisville, Kentucky (home to managed care giant HUMANA) in the 80's my then group of 5 physicians decided it was a matter of sinking or swimming. Humana manged to pretty much take control of the insurance plans of corporate entities in the region and, if we wanted to have any income, we had to play their game. It wasn't long before the rest of the insurance companies followed suit with their versions of managed care. Paul, opting out was not really a choice physicians could make. When 90% of your patients were employed by business that were now providing only managed care plans, turning your back on them and refusing to see them was not fiscally or ethically possible. We had no more leverage over the insurance companies then than you do now over the oil companies and their high cost of fuel. And, remember, in the 80's, we did not have a significant shortage of primary care physicians. There was also the concept of the primary care physician being the "GATE KEEPER". This was in some ways similar to Martin's "MEDICAL HOME" model and, it did empower us to some extent to control patient's self-referring to specialists. In theory, it was not all bad but, like many other good intentions, people got greedy (insurance companies) and they started suffocating physicians with more and more restrictions, paperwork, performance monitoring and less reimbursement. Martin's Medical Home Model would be good for us and good for our patients but only if it is controlled and monitored by us, not the 3rd party payors. It needs to be a tool to improve patient care, not reduce expenditures for care.

Leslie

Both of you make very good points. The problem is that, as the HMOs have become more powerful, they have modified the rules so that, in primary care, even by accepting HMOs you can't survive.

I believe Paul has mentioned that one insurer has most of the market share where he lives--so they use their near-monopoly power to drive down physician re-imbursement. As the Blues do in so many areas when they control the market.

Guys,
Leslie just said in a perfect example exactly what I'm getting at. Do you really think these SOB's care about patient outcomes? They trade pts every 6 months to a year back and forth. Yes the HMO model was supposed to be a good thing that put primaries at the center of the whole deal, paying you well for your managment and gatekeeper function that would save lots of money for everyone else. But you guys are not voting members of their board, voting shareholder who are the owners of the company, so they did exactly what they do best. The cut you all down to nothing while keeping all the good stuff for themselves. As Leslie says, they changed the rules, increased the bullCCHIT paperwork, tied you up in knots, and you are still handcuffed by the same anti-trusted laws (No Leverage to fight back with) that they are free of to do as they please, screw you 6 way from Sunday.

So what makes any of you really "smart" analyticaly thinkers, students and practioners of science think that this P4P won't end up doing the same exact thing??? Please get a CLUE! They probably planned at least half of what we have today, and I'm sure that if we could execute supenas have get a look at their internal memos and the minutes of their board meetings, see their rollout plans, bug their board rooms, I'm sure we'd find that this P4P is no different. I'm sure they are already planning on using this P4P CCHIT to get you all on board, and once they've got the magic majority number of you by the they plan on pouncing on all of you, to them turn the tables on you, change the rules, keep cranking it up over and over again, until you are dead. Heck most of us can't run our practices on the crap they pay us now unless we see too many patients. I feel any PCP office that sees more than 15 patients a day is not practing proper medicine. The average primary care visit in now 7 1/2 minutes!!! 7 1/2 minutes, like what kind of hiding issues, follow up to previous issues, digging and counceling and teaching can you be doing in 7 1/2 f'ing minutes??? Please Henry Ford has cranked up the assembly line to inhuman speed and now the SOB wants to know why the fenders keep falling off all the cars that are coming off the freakin' line!!! Give me a break.

Mark my words with history as stated by all of you above on my side, P4P will be the last nail in the coffin of Doctors making a living at primary care. In the not too distant future we will have nothng but factory sized practices with on doc supervising 10-20 mid-levels doing all the primary care. Heck even the AMA and almost every other doc in the system dis's you and has no resepect for you and your offices. I know I'm the guy who gets pissed on as they call demanding their referal even though both they and the patient are trying to get around the gatekeeper function you are supposed to be playing by getting a referal for a specialist visit even though the patient hasn't seen the primary to discuss the issue and get her blessing for this referal.

You guys are toast and either you can make a last stand to try and save medicine and your profession now, or down you will go. Anybody care to take me up on my sucker bet???

Nancy and I are starving our way to our convictions as we trying to come up with some way of still making a living doing something in medicine that does not allow her to be screwed into tons of paperwork for a lousy $50 level 3 visit. We are going to be doing the Suboxone therapy soon, totally changing the patients life and the lives of everyone around them, saving their carrier $25-$100K from revolving room ER visits, OD's, repeated trips to detox no less all the cash this will save society and the local and regional tax payers. But how much do you think they are going to share their savings with us??? Heck I bet the drug company whose product it is, is going to make as much if not more than she will, while we are the ones doing all the hard work dealing with these difficult patients and managing them and their negative behavior until they are well... Why can't they honestly share some of these savings with the doc willing to take on the hard work to save these people's lives and everyone, and I mean everyone lots of money???

As Leslie said a while back, "isn't it a shame that today PCP's need a schtick just to make a few extra bucks?" Just wait until they are done with you with all this P4P cchit. Why does everyone hyper-control us, but these carriers can make tons of cash, keep their books and their offices closed to the people and the gov't and get away literally with murder as they kill their patients with their terrible policies and procedures? Why can't we get that same immunity, not that we should. I want P4P for the medical industrial complex first, after we sceeze their like they have done to yours, then and only then can they come back into my office and ask me if we have any more efficencies to be found.... Who makes more money, has better bennies and retirement plans, the average solo PCP or the a provider rep for a major insurance carrier??? I think I need to go gett measured for a few suits so I can go get a job on the other side of the street as a provider rep and treat you guys the way you all seem to be saying "bring it on" for....

Please my friends read the writing on the wall or we are all doomed! Please! Please, please....

Paul

I agree that it is not really pay for performance, but pay for charting - If I provide the same care as JOE BLOW, but his chart has more templates about warnings, recommmendations, etc. He will get a better rating. It isn't fair, life isn't fair, but we all do the best we can to provide good pt. care.

Leslie's note about WalMart scrips hits home, but most insurers when you really get an audit will accept the fact that I have referred, advised, prescribed and ordered tests/meds/other issues - at least here on the West Coast. It is sad that I actually write letters to patients advising them that there refusal to have an eye exam for a diabetic is an issue - I would love to just tell them and move on, but liability says I have to cross my T's and dot my I's.

Unfortunately primary care is undervalued and if that is going to bother you then you have to change jobs, professions, specialties, etc. because it is unlikely to change. The west coast has a lot of HMO insurances, various PPO's -- it is still possible to make a very good living, but you have to work. I personally work in the hospital, in the ER and in my office.

Paul said "In the not too distant future we will have nothng but factory sized practices with on doc supervising 10-20 mid-levels doing all the primary care."

He's right on this. I remember 20 years ago in DC, our HMO was Group Health Association and I recall hardly ever seeing my actual supposed dr. I nearly always saw the PA. And the ONE time that the Dr. did want to see me since the thought the problme was "weird" I overheard her complaining about him not trusting her judgement. Really, two times in a 5 year period is all I actually saw the dr. And that was between 1978 and 1985. oops. 7 years. I can't count.

The sad part about the midlevel issue is that physicians themselves created much of the problem with their greed and desire to high lots of them to run clinics with physicians as the medical directors and make more money. There is nothing wrong with PA/NP as long as they do appropriate work and their is physician involvement.

I know that this is one of my longest to date, but please try and deal with it and see it through...

Chicken and the egg here folks, chicken and the egg. Which came first, all of us punting to find a way to make a real doctor's income in some crazy inside out, and upside down market? Or perhaps the CARTEL's who control our access to our own end retail consumer of your services, who have been able to artificially stagnate and reduce your fees for twenty years now, so now all of you are punting???

Come on now, put on your thinking caps, return to real analytical critical thinking skills, and see where this all came from. I say that if we had a solid and steady ecomony where folks were able to afford the things in life that they needed and that the real regulations that were needed were inflicted upon super larger, multi-national corporates with almost a totally free market for micro and small business our economy would flurish like it hasn't in almost half a century. Funny how all the talking heads have suddenly rushed to small business to buy a few votes, but all the deregulation, tax breaks, a one sided legsilation is always written to the advantage of those super large ones. "They need to make enough money to afford to buy my cars."

We have allowed these mega no national pride or responsiblity bastards to rape your nation and our people to the bone, drive down wages while still charging us prices for goods and services as though the products were still produced on shore with union labor. Who do such policies serve? The majority of Americans? Certainly not. The top 1 or 2 percent, definitely. Are the insurance carriers any different? Or Big Pharma, GE, Welch-Allyn, and many others? Why is it OK, just accepted business as usual that these folks should be the ones to profit from all our hard earned healthcare dollars, but not the practioners of the actual plying of the art and trade of medicine folks like yourself.

Without you the whole damn thing comes to a grinding hault. No Rx for a scan, no MRI's test to make money on to pay for their extremely profitable machines. No Rx for drug therapy, no drugs sold for their extremely profitable drugs. You guys are at the heart of it all, the center of this universe and yet you can't walk away being properly compensated for a good days work that gets a good days pay.

Ya see I haven't mentioned this lately, I would love to see basicly affordable primary care, not to be covered by this crazy system because people need to apperciate what they pay for and what they get, and while they basically get it all for free they seem to apperciate in not. But to have real good old fashioned covered out the butt Major Medical so nobody goes poor from really bad illnesses.

But I see so many supposedly poor people who they and their kids are on S-CHIPS health insurance plans that pay crap, who still have $50-$75 a month cable TV subscriptions, cell phones, $20-$40 a week smoking habits, probably the same for some of them for beer and booze too. But god forbid they have to $75 to visit their PCP for a sick visit. Sorry I'm not buying it.

I know I was a working class kid from the Bronx. Do you want to know just how many patients we have here on some form of gov't support insurance and they are small business owners and contractors almost certainly scamming away? How many of them are driving nicer cars, their homes are in better states of repair and they can afford to eat out more than we can??? But we're supposed to take their cheap@$$ insurance that frequently doesn't even pay Medicare rates? I need to post some pictures of our house, my roof, our collapsing fence, and my 188K mile rust bucket Jeep. We're a F'ing doctor's family and we live in the house that is in just about the worst state of disrepair in the entire community!!!

Now I totally agree that people should not give up their nest eggs just to pay a doctors bill, but how did we get here and should those of us who had nothing to do with what happened 20-30 years ago "back in the day" have to suffer all these repeated rules, regulations and insults while having nothing but stress and worry to show for it??? I think not! We need to level the paying field between doctors and insurance gov't or private, grant us an free and clear anti-trust waiver for the purpose of having national strikes and organizing.

All of these issues, what kind of reporting do you need to have, how much and what kind of work, and under what terms and conditions, how much work for how much pay, these are all really "Labor Managment" issues that should be hammered out across a collective bargining table. I know, I'm a founding member of an IATSE local, Local 481, New England Studio Mechanics. I was one of a number of folks who were in on the writing, and wrangling back and forth creating a constitution, and creating and electing our first board. I've been to the Goerge Meanie center in Maryland for organizing training.

As long as they have us all divided up because only our side is artificially and wrongfully constrained by anti-trust laws because we are supposedly all private contractors, (we're not they control our access and fees to our customers of end retail services) we can never have a positive effect on any and all of the issues that affect us and our patients. And yes we too are consumers of healthcare, and every month that I have to cut an obscene sized check to cover my family of four to the same SOB's that treat my wife like dirty and pay her CCHIT it makes my blood boil.

I say we need one insurance pool that by law must be put in an "Al Gore Lock-Box" (the same should be set to Medicare and Social Security that both have big, nothing but funny money IOU's in the boxes right now) to be conservatively managed, for modest and safe rates of return. Think about it, I know I pay almost $11K to cover my family and four and even on a year that one of us has a small issue or an interesting scan we are probably not using more than $3-$5K worth of services. Without the SOB's in the middle stealing the best for themselves, if just left there for the next twenty years and invested wisely there should be plenty to care for Paul and Nancy when we grow old and grey. Espeically if we actully half bargined all the other rich greedy players in the this system of a change and had then finally have to work of reasonable margins that still far exceed our own. It is time to stop taking meat off our our bones, and start to really trim the fat everywhere else first, not a dollar more from us, espeicially in Primary Care, until everyone else has been hit for as much and as long as we have.

One collective national insurance pool, combined with collective bargining for the providers with a real right to strike is the real answer to all of this. What kind of work we do, under what conditions, how much for how much compensation, who do you report to, what are the measures of your work, out put quantity and quality, these are all labor managment issues to be hammered out in collective bargining. Nurses and tech's certainly have it for the same industry for very similar measures and issues, so why not you? And you really can still work for many employers at the same time like you do right now for all the Cartels. We do it in both my indurstry as stagehands as well as many construction workers just to name the two most know industries where this happens. I used to work at two or three places all in the same day or two. Didn't stop me from being declared labor and not a private contractor and having the rights of association and collective action and bargining, and it shouldn't for you. They are dictating so many of the terms and conditions of you work that they basically have made you employees. Heck they even claim to have a vested and financial interest in the end output and quality of your work, this is a really big one for determining if a trademen is an employee or a private contractor. They even control which customers you can or can not work with, your call schedule is demanded to be 24/7, they tell you when to work! Give me a break.

Hey perhaps I have this all wrong, pehaps I should work with all of you to hasten the implimentation of P4P, because once it is in full gear, there will be no denying the docs are employees instead of private contractors and we can finally get down to striking, picketing, hard across the table negotiating, force them to finally "Bargin in Good Faith" which they certainly have never done in all of modern insurances' history, via the NLRB and the laws that govern such, and finally we can start to fix things for us and our patients... OK I'm with ya now, P4P it is.

I'll only accept P4P under a collective bargining style terms and conditions properly negotiated via such. This would at least allow you folks to ability to have real science and real math, access to all the data, their's too, to hammer out what is measured and why. Real quality or is it just bean counting? Or is it bean counting maskerading as quality which I'm sure most of it would turn out to be. Under such conditions they would probably abandon half of it. Funny how when employers have to pay themselves for quality programs how many of them suddenly get very adverse to the idea..... Don't you think that is funny, I sure do. Just like worker safety programs. Bitch about the cost of compensation coverage and your ratings, but when suggested they actually take proactive actions to reduce injuries and therefore save money and human carnage suddenly they get cold feet.

I'll be with you on your half if and when you're willing to be in on this on my half. Only if bargined in good faith, openly in a fair collective fashion, with the real threat and right (no Taylor laws) to strike. Only the right to withhold services and to put the hurt on the other side, has ever brought really tough issues into allignment and forced both sides back to the table to settle things in a positive fashion for both sides... Now who's with me on this kind of P4P???

So in short, collective bargining first, then nationalized healthcare and P4P only afterwards. This levels the playing field and gives you guys like kind leverage to negotiate back in the open, on a fair and level playing field, using your unique skill set, knowlegdge and training as the bargin chip it should be seen as all along.

"Solidarity forever, solidarity forever, solidarity forever, our union keeps us strong!" Are ya with my???

Good Night and Good Luck,
Paul

LOL. Man, Hockey. I think this is your longest to date.

Union? Probably not as this is not in the nature of many independent docs. But you are definitely correct that the 3rd party payers currently hold the cards relating to reimbursement. The system has to change starting with medicare.

The Heritage Foundation has a very good article on this topic.
Check out this link:

http://www.heritage.org/Research/HealthCare/wm1931.cfm

The primary problem from their (and my) perspective is the artificial price controls put in place by Medicare and then logically followed by most insurance companies. If we could balance bill, then docs could start charging market rates and finally be back on the same playing field as plumbers, lawyers, electricians, etc. Medicare could still be a stingy payer but at least physicians will have ability to recoup their costs and be paid appropriately near what the market will bear.

Price controls were long ago shown ineffective in the USSR...now we just need our politicians to realize this is exactly what they are doing to medicine with Medicare.

P4P should not be implemented until these price controls are removed by allowing balance billing.

Will balance billing ever happen again? If anyone has actually written their senator or congressman on this topic...then maybe, but I doubt many have. Until we push for this both individually and as a group, we will continue to see the negative effects of price controls on medicine.

I had a following the progression of this topic since its inception. because I'm somewhat biased, having worked in developing a P4P program, I wanted to make sure that I have a balanced evaluation before I wrote anything.

Paul's comments are mostly accurate. Insurance companies motivation for P4P probably varies from truly accentuating quality to trying to minimize payment.

Unfortunately, P4P HAS come about partially because of poor charting, there is also an element of poor doctoring. Then there is the issue of greed, both on the insurance side as well as a physician side.

Sure, there are things that P4P requests that are not appropriate, but many of the items have a sound basis in medical management, and are appropriate things to do.

The question becomes, 1) how to do the right thing and 2) how to make it easy to track the right thing.

Some things, such as diabetic management, are significantly aided by using graphs, spreadsheets, and flow sheets. A good P4P program should reward this.

Then there is the issue of the insurance companies, and ultimately the money. On the one hand, the insurance companies are looking for the most appropriate (cheapest) method of care, as well as looking for an out to wait having to pay for services.

This is compounded by having multiple insurance companies looking in multiple ways for multiple things, with all the multiples that multiplies.

P4P is not inherently evil, but it can be used in ways. It should reward physicians who adequately document. It should help a physician practice more efficient medicine. Currently the entire P4P processes in its infancy, and therefore there are good and bad examples of how it is being used.

I have been involved in a PHO where we developed our own P4P program. With our program we have selected physician and put on the front end, developed a methodology for scoring and information gathering, checked for medical validity for the items being evaluated, and have the staff's doing online information input. The physicians were involved on every aspect of the process. We currently have over 98 items that we measure affecting a variety of specialties. The process is very much, heavily weighted towards the PCP's, but over the last year and a half, we have attempted to increase the requirements for the specialists. It is a burdensome process, both from the development of the process, the implementation and maintenance of the process, as well as the and put out information and analysis of scoring, ultimately leading to points towards payment.

Having gone through this process, I have noted that even with the best intentions, there are staff, who are anti-physician, or do not give physicians the benefit of the doubt. This entry at our own bureaucracy, which is every bit as burdensome as working with an insurance company at times, however we are more flexible. if that can happen in an organization as heavily position weighted as ours, it would be frightening to consider how it operates an insurance company where there is minimal physician input. Having over 400 adversaries in different insurance companies, makes the likelihood that most systems would be physician friendly highly unlikely, unless the process is created by physicians.

Without a doubt, having an easier way to input information would make the process much simpler. This is an area where an electronic medical record can help.

One goal of electronic medical record is to make the process more streamlined. If they can transfer information more efficiently, that would be good.

As to the whole process of CCHIT with its mandated information up link, this is far too Orwellian and lacks the ability for us to control the flow of information. The physician should have the ability to control any release of information, although by the same token, the information should be recorded and available. Better charting should be rewarded more handsomely. ultimately the ability to provide the information back to the position to make an intelligent choice should also be readily available. Again, that is the goal of an electronic medical record, and is one area where Amazing Charts seems to outstrip its competitors.

It goes without saying that primary care should be rewarded much more as it has the ability to control finances more than specialist care

Excellent and thoughtful replies there folks. Now at $4 a gal for gas how much do you think Medicare and all privates should increase their fees for some poor primary to get in her Jeep with 10" of snow, loose two short visits on either side of her trip just to give some poor half bed ridden old lady (somebody's mom and grandma!) a good old fashioned housecall. I'm not in the least bit embarressed to say in light of reduced fees, inflation, doubling of malpractice in just the four years we've been open, I think our actual charges are not high enough, no less the fact that none of the majors can even meet them.

I have a quick question for all of you and I want a honest reply and if the answer is no I want you all to promise to go do this for at least two if not four fiscial quarters. When was the last time any of you regularly watched for the quarterly reports of all these insurance companies??? Just go to their own investor side of their websites, and simply use their own data. I have been paying extra attention to UHC because they are the cheapest paying of all of the Majors in our area. Way below present day medicare each and every year we have been here. And as the practice manager who shops for employee bennies I can tell you that they undercut most plans by about $100 per month to cover a family of four. No wonder more and more employers want to give them a try. And where do they get all this profit and undercut most other plans, by squeezing their PCP's . That's how.

On average for every quarter I've ever checked UHC posts at least 3/4's of a BILLION dollars worth of profit each and every quarter! Ya I know, I had to do a double take and check the first time too, I just couldn't believe it. And remember this is after they pay their obscene compensation packages and other slush money, lobbist, and other funny funds, this is actual publicly reported profit! This is money that will never be seen by you or I whether as people in the healthcare profession or as consumers of such services either. These people are PURE EVIL. How dare they squeeze both us and our patients so while they are literally rolling in it like pigs at a feeding trough. And this is just one of the two largest carriers in this dirty business. Remember all the others be they BC/BS affiliates, CIGNA, AETNA, WellCare, Humana, Keiser, should I continue??? Each and everyone of these dirty bastard companies are doing like wise.

And let's not forget that part of what they all want to do is make more and better paying jobs and titles for themselves and their friends inside the company and this is all before the posted profits. Then there are all the other pigs at this feeding orgy like the large manufacturers, Big Pharma, now the CCHIT level software vendors who work both sides of this street so well, playing doctors office of of insurance carrier so we have this billing software arms race going on. "I'll just sell arms to both sides and make money in the middle" Hey is it the carriers or us who are supposed to be the Sneeches with stars on our bellys, I forget now???

One of the most profitable small companies here in our area is a medical recovery firm called Med-Rev. Unreal, more parasitic lose for us for someone else to make money on. Anyway, when all these greedy and inhuman SOB's who literally kill people with denying care and cheat docs and patients every day, finally get properly cut back down to size and have their bank accounts and profits raided like we have ours, then and only then will I be willing to listen to anyone wanting to do anything but raise our fees without us having to do anything but say, "yes you're welcome, yes you're right we were giving you pretty darn good services under some of the most obscene conditions and pressures. Thanks for understanding and finally paying up".

And remember when we contract directly with our patients with no insurance, then the entire concept of "insurance fraud" and give backs for improper coding and all the like goes right out the window. Oh and the research is clear, on average almost all docs do "undercode" already, so there is really not a reason needed to be asking for P4P or give backs, we are already cheating ourselves for fear of running amuck with these SOB's. They don't need nor deserve any more give backs. It is my contention that the AMA themselves is guilty of colluding with the gov't and the carriers for having their stupid little coding system in the first place. Heck you guys are supposed to be private contractors, they can't tell you how to document, code or bill and god damn thing, that in and of itself in a clear violation fo free trade. I don't care to bill with with 99213 and 4's, I want to use a two tiered office visit system. Or a time based one or what ever the heck you care to use. The AMA should get out of the business of assisting our oppressor and you should all be angry as hell at them for colluding with the enemy! How 'bout them apples?

But in the end we need the right to act and work collectively against a large corporate monster that has those same rights. Then and only then will we have the semi-equal leverage to fight back against these animals, these piggies. Without us having an equal say to hammer out what is measured how and when, what kind of out put for what kind of pay, it is all just a means to continue to keep us all tied up in knots and reduce your fees ever downward. It's a great sounding catch phrase, George Orwell would have been very impressed, but in the end it is just anther new set of tricks to pick your pockets and bleed you dry, while they stuff their fat faces ever more.... That's all. Sorry I'm not buying it and I never will until all the other conditions are met first. (and even then....)

Good Night and Good Luck,
Paul

The president of United has received bonuses of hundreds of millions of dollars several times in the last decade, if I am not mistaken. One person. This is obscene.

There does need to be a standard. I wouldn't argue as much about the CPT as ICD codes. They were not designed for medical use. They were taxonomy codes. And where did this concept of 3,4,5 digit code that we can't pay you if there are not enough digits.

Sometimes it's not the system (CPT,ICD) but how it's used. This goes back to the insurance companies.

If we are really trying to cut the fat out of the medical system, why would we have over 400 companies, each with their own rules and burocracies? It would appear that the insurance companies are trying to confuse the physician, the patient and the employers. It's not designed for better information flow, but rather to make it more difficult to understand.

It's about control, power and greed. With invasive amounts of knowledge, coding habits, chart reviews, pre-existing conditions so on and so forth, comes control. Especially when combined with their insane one side only anti-trust waiver that allows them to walk all over us. Again this one issue needs to be screamed from the roof tops, every time any of you are in front of a reporter, a TV camera, writing an article about health finance reform, this one issue is the key.

How many patients are wondering and even ask, "well why don't you docs, you managers in the business who understand it all, Why don't you do something about it?" They think one that we don't care, and two we are glad to be getting paid lots of money (yes most people still think that the average doc is over paid and rich, need to fight that image too), and most importantly they have no idea just how tied up by unfair laws we are and how emasculated and powerless we all are. This is partcially because every time the talking heads talk about special interests and health reform, up comes the "powerful" AMA. BullCCHIT. They certainly don't represent my wife power or not.

But with control comes power and with power comes more control and they sort of feed on one another round and around. And once you have that you have the ablitiy to influence and manipulate things to your own selfish advantage. And once you have this kind of synergy happening around you, comes the rewards of power, lots of money. But lets not forget that alot of this does really go back to people with big egos and self important images, and that being in control and having others play to them just feeds into all of this. This is practically a personality disorder that has been given a pass and even is looked up to in our society. But the three concepts, power and control that then equals many and various rewards both financial and otherwise is key here. These folks thrive on it and are pretty much addicted to it, feel self entitled to it and are not going to give it up willingly. And as we all know; "Complete and total power corupts completely". These guys are just so totally out of control. They almost need a form of shock, intervention therapy!

But DW makes a great point about the compensation and bonuses these bastards make. Question who here in this system has a lowly MBA at best most time and who went to med school and residency and is licensed to practice medicine. And yes you are also correct that many of these issues are false ones meant to control, confuse, deflect and disarm the actual debate and facts that we need to be discussing, and that is one of my main points here, those real issues that we should be discussing like Exec compensation for denying and messing up healthcare? What the F%#&?

If and when, and only after these terms and conditions come to pass, if and when each and every one of their corporate officers and even just mid-level Execs have to live on the average income of the average primary care physician, now at approximately $150K (pretty sad, how many are under that figure like my Nancy and many of you too, just to reach that as an median average, right?) then and only then will I start to be receptive to the idea of discussing more policies to control what happens in my office and in the office on my doc or any other.

This is just a deversionary tactic, to make them sound like they care and are attempting to do something and it is our side that is messing up healthcare. Again George Orwell would be very impressed. Probably very upset too but none the less very impressed. These guys are experts at this kind of reframing of the issues and confusion and deversion. Please don't fall for it!

Question: We all have a friend here with a few connections down in the DC area. It is clear to me, that not one of the organizations that many of you have bailed from years ago, APA, AAFP, AMA just to name a few, or some of you are still members of just don't get it and really don't represent us worth a Darn.

How many folks here would be willing to throw in a few bucks a piece to get one or two people down there to speak for us and to do regular press releases and conferences, and perhaps a blog too? I'm thinking perhaps $50-$100 a piece to start. But these kind of things take money to keep going and to pay for transportation and to properly and legally start a entity. It would be so glorious to start some grassroots thing with docs and patients as members (patient member $10-$20 bucks with perhaps a $5 membership for folks on SCHIPS, Mediciad and public assistance just to cover mailing and admin costs perhaps? Hey if created properly we might even qualify for grants or other public funds). An organization that educates the public and redirects this agrument in the direction it should be in and not the one that these SOB's want it to go in and away from them who are the main culpruit in this mess... I think the good will alone with our patients seeing that we actual care, get it and are willing to spend our time on it would be priceless.... Anybody game???

PS: It really is anti-free trade to insist that all tradesman in an industry bill in exactly the same exact manor. It is, really. When Nancy and I were real private contractors years ago, we had to create our own bills for our services and no one should be able to tell you how to do this. What is so wrong with having a different system for billing similar services? You guys have been in this stupid system for so long that you have no idea what is going on in the rest of the real business world all around you. In real business, all other industries but ours, things are done so much differently. Again it is the powerful that are controling all of this for their own not very well intentioned self interests....

How about good old fashioned time and materials like most micro sized, private contractors who pull down the same if not frequently much more than you guys do??? You really could run an entire small or medium sized practice on QuickBooks, private contractor version. Yes, "Private Contractor" version. It is my firm conviction if you can't run your business on something like this, then probably the situation you are in is illegal and a clear violation of freetrade laws. There is one for Professional like lawyers who bill time and materials. Now that is real private contracting. No the CCHIT we have to put up with. That is NAFTA style free trade, screw the average American in exchange for the obscene profits of a corporate few.

I think any time we do anything, that is billable time as we should all get away from this "colluding with the enemy coding system". The guy who comes to fix your roof, install a new furnace or HVAC system, your lawyers, all of these guys bill any which way they want and nobody can or should tell them how to. Telling them how to and forcing them to do such is a clear violation of freetrade, plain and simple. And most of them bill some form of time and materials, where you know it or not. Every phonecall, every form filled out, every managed care referal, every small conversation about a patients condition with staff or friends, this is all billable time in a normal real freetrade situation. Only not in yours.... And if you don't believe me, try this for a test: Call your lawyer because you're really upset at 10 pm on a Thursday evening for a "free consult" and see how far you get, tell me what kind of bill you get in the mail... Same idea, send him a five page form for him or his paralegal to fill out for you because he is the pro who has your info and the knowledge to properly fill the darn thing out... Let us all know how and how much he charged you for such services. Please post here for all of us to share and continue this conversation in a more positive, and back on track in the proper direction....

You're a freakin' private contractor so says the gov't and the carriers, that is why they hammer any and all of you for talking and colluding so hard. It is amazing that in an industry with such strong controls with the gov't watching so closely for collusion, that all the supposed private contractors in the industry all use the same exact way of billing for the goods and services... Don't you find that a bit concerning and upsetting??? I certainly do. Who is in the driver's seat overly exerting control that all these private contractors are billing is such a consistant manor that it is a clear violation of real freetrade???

So you should all insist on billing and acting like private contractors... Any way you darn well please! So until you guys are allowed to organize and act collectively, and work out hard fought bargining contracts you should all insist upon your protected rights to bill any gosh darn way you feel or want to... Real freetrade under the real rules of private contracting. Sure seems so simple and obvious to me....

I agree we need to talk outside the AC community about P4P and the gradual failure of the medicare price control based reimbursement model in medicine. I would encourage us to start by posting to outside blogs with more readership, such as Wall Street Journal Health Blog

http://blogs.wsj.com/health

Problem is, just like with battling legislation like the SGR or 10.6% cut, physicians just don't have inclination or time to insert themselves into this debate. Until more do, we won't make needed improvements.

I plan to check out alternative models for our practice, such as those promoted by these two sites:
http://www.simpd.org/
https://idealhealth.wikispaces.com/

Maybe I should make it to the IMP camp that Paul is attending.
http://impmo.org/register.asp Not too far from Michigan, unlike Branson distance issue that joseph2 and I share.

I'm happy that Brian turned me on to the Yahoo forum ( http://health.groups.yahoo.com/group/Practiceimprovement1/ ) with one of his earlier posts and these discussions really have me thinking that change has to start practice by practice rather than through a major system overhaul. Makes you realize that there are many others thinking along the same line, even though we are not "unionized" like Paul is suggesting.

Here is an active WSJ blog today, talking about the impending 10.6% cuts. Since a vote failed yesterday on postponing the cut, it would be great to see this loaded up with actual physician opinions:

http://blogs.wsj.com/health/2008/06...octor-pay-fails-key-vote/#comment-184161

Eric,
I am trying my best to get regisitered but so far the folks that Dr George recommened I reach out to have not gotten back to me. So I just left her a voicemail. She may still be seeing patients being that it is but 3:30 her time out there. Perhaps she can just put a couple of chairs aside for us. But sure we'd love to see ya there. Lots of AC users in the group from what I understand and I just might log into our office from there to show off FAP for a few moments too at some point.

And yes we really do need to bring these facts and topics to the people, redirect the conversation to the real facts instead of allowing this malintentioned other side to dominate all the "spin" all the time. We need to organize and we need to fight back in the court of public opinion.

But it starts by explaining these difficult concepts as a groundwork to understand all the other points. And most importantly, not sounding popus and self interested, but from the perspective of what is best for both of the two real parties in the relationship, you the docs and they the general public the patients. These folks are just blood sucking leeches draining the good out of your relationship. They the interlopers here that have made this relationship so dysfunctional. They are the ones that need to either be heavily reined in or totally cut out all together.

This should be easy, most people like and trust their PCP, while they have a real distrust and active dislike for their insurance company. With a little work is should work. But nobody does in an organized fashion and that is why I seriously think we need to form a pro-health, pro-patient, anti-medical industrial complex activist group run by good folks in the small and solo side of this business.

We do care, help us to make a decent living and get these SOB's out of our hair and we will gladly work our butts off for our patients. Just think of all the wasted energy we put into feeding this dysfunctional system. Imagine if we could just be free of all their horseCCHIT and be compensated fairly and had all this time back to properly focus on the important issues like caring for the actual patients, running our practices, and continueing medical education... Just imagine. More cash flow, more and better conferences and classes, and the time you need to have deep and meaningful relationships with a proper modest sized patient panel... It would be glorious!!!! But we need to explain the reasons why things are just so messed up and paint a picture of how things might be under a different system that is free of these greedy, for profit, anti-health blood sucking pigs. The more I think of it the more I think if we really framed it in a way almost like the "peace dividend" that these guys are the bloat and the waste, not us, we have been cut to the bone already, we could provide decent care for most people in this nation at a much more reasonable cost. They are the main problem. They make money by over charging for the care and then underpaying us for it and denying it for both our patients and us. It's so simple really...

I have one last question for those of you who seem to know your history better than I: Now granted there were a lot of surgeons and other specialists who were rolling in it back in the day, but honestly I don't seem to ever remember my middle class very left wing school teacher parents ever bitching to much about our primary care docs. As a matter of fact I basically remember them speaking very well of them and having a lot of respect for them. Now I remember my dad bitching frequently about the SOB's from our health insurance company even back then asking for tons of forms and not paying for things and general intentionally getting it wrong. Back when patients had to do their own claims with their insurance carriers. I think that this one area that we should ask the public to take back if they want us to keep doing business with them. Hell it's your insurance company you deal with them, we didn't want them here in the first place.

So tell me how many PCP's were really fleecing their patients??? Because I get the feeling that even back then when they could have, whether is was good old market forces like people would only pay so much for a cold, a well check or what have you, or the good nature of most of the folks on this side of the business that PCP's prbably never got too out of hand. Now I could be wrong, but that is my impression as someone who was a kid, teen and a young adult back then. Sure it was expensive compared to other things in life, but was it really that out of control on the primary care side??? I'm not so sure it ever was. And I sort of see it the same way now. Big hospital bills, procedures that still pay darn well, be not what they used to be, expensive equipment and drugs, while PCP's are the only people who get their squeezed here.

Thanks much and have a great weekend one and all....

Paul

Eric (just PM'ed you),
And any one else who can't make the AC Branson conference but would like to and could attend one in Rochester NY here is the latest link to sign up from Dr Sharon George who is one of the main people running the thing I believe. Anyway here it is:

http://www.impmo.org/Register_LIVE.asp

And Brian thanks for the tip! 20 CME credits, so there Branson!

Unfortunately I still can't have too much to drink because Nancy and I will be commuting it and probably in two cars the first day on account of the kids school schedule.... You Branson guys drink a toast to me and my better half, and to Village Medical of CNY. Have a good old time and enjoy our share to the hilt. We'll catch ya on the other side I guess... Cheers!

Paul and Nancy