How Your Health Care Works, Part III "statistics"

When I first began to study statistics in undergraduate my professor said, "there are three kinds of lies, there are lies, damn lies, and statistics". It wasn't until many hours of study and conversations that I fully understood what he meant. As a practicing doctor I was often frustrated with the media's reporting of studies and stats. "A recent study showed......!" The frustration came from the general population's acceptance that if it came from a study it must be true. Pharmaceutical companies, politicians, and media agencies use such generalizations to sensationalize or drive home a point or opinion that they support. This is actually dangerous, you can see some of the most blatant misuse and ultimate effects by looking at the Vioxx debacle. How many people died because of a misuse of statistics? This is one that you know about, how about the misused stats that we are depending on today to make decisions, that we will find out later are killing us?
When explaining this to people I have tried to use everyday stats that we make general assumptions about. 1% fat milk! sounds great right, must be 99% less fat? Actually milk is only 3% fat to begin with, so it is 66% less fat. Overall it is unnerving to consider that we accept stats from anyone with an agenda, they can be spun, adjusted and presented in a way that can ultimately influence us to make choices that are not necessarily in our best interest.
Here are four pieces of advice to help with stats, you don't need to be a statistician or even college educated.
1. Consider the source, what does this person or organization have to gain by presenting this statistic in this fashion?
2. WAIT! any truly significant statistic that changes what we do or the way we think will surface again and again, the rest will ultimately be dis proven and you will never hear from them again.
3. Ask as many critical questions as you can, assume it is bullshit to start. I know, sounds rough but, if you change what you are doing and it ultimately turns out like say, vioxx, you will be dead and it won't matter. If you assume it is crap until "proven" otherwise you have lost nothing.
4. Whenever possible talk to an objective professional who understands statistics. Admittedly there is no one who is truly objective, but at least someone who has your best interest in mind and at heart.
In medical care when beginning a new treatment I suggest you ask the "number needed to treat" (that is how many people are treated with this before you get one good result?) If the NNT is 500 but 1 in 5 people get side effect, well, whether or not you risk it in this situation depends on how serious the condition is. The decision is ultimately up to you, but be informed. I further recommend that you ask what the top five side effects are and how many people end up with those? These questions can ultimately be extrapolated to procedures, surgeries etc. Finally, ask how this treatment, procedure etc. compares with others, if it is no better than say, a cheaper, more well known treatment or procedure why are we even talking about it.
In closing, statistics are complex, obtuse and unfortunately adjustable. Remember a statistic is not "THE TRUTH" be a cynic, it will serve you well!!!

How Your Health Care Works, Part II

Now that we know who makes the money, how it is supposed to come in and who pays it, lets talk about the billing process. As I said in part I, only face to face interactions are paid for. When these interactions happen two codes must be submitted to the insurance company, an E&M code (evaluation and management) and a diagnosis code. The E&M code is intended to represent the type and intensity of the visit, type meaning; procedure, counseling, diagnostic etc and intensity meaning low such as a cold, or high such as a person with heart disease, kidney disease (or other chronic diseases) who need complex medical management. In the PCP office the most common codes are 99211, 99212, 99213, and so on (99215 being most complex). Then a diagnosis code must be assigned for the disease or symptoms. Here is where it gets weird, as a PCP if I use the diagnosis code for depression I generally wont get paid because that is for mental health providers, I can treat depression, as you know most depression is treated by the PCP in this country. I must then bill for a symptom related to depression. This is one of hundreds of rules put into place to delay or deny payment, and the rules change as we go and are different with different insurance companies. Additionally each code requires a note that shows I did a certain amount of work. For a 99213 I must ask and record; history of presenting illness, relevant associated symptoms, review past history, and examine a certain number of body systems!!! This has nothing to do with whether or not I believe this to be medically necessary, but if I bill a 99213 and do not live up to the insurance company requirement (standards are often set forth by Medicare) I can be charged with insurance fraud!!!! Note, that when you bill the higher more expensive codes on a more regular basis you are often examined, in two years I was requested (and required really) to send copies of several notes to prove that I had done what is required to meet the standard of a particular code!!!!!
Here is how you will get paid, for every E&M code each insurance company has a MAB (maximum allowable benefit) this is what they will pay you for this code, note however that this amount is different with each practice and it is actually illegal, that's right against the law, for me to ask one of the other practices in town what such and such and insurance company pays them for a particular code. Basically they pay you what they say they will pay you, if you don't accept it they will remove you from their preferred provider list and tell all of their patients that you are a non covered physician (thus you will lose significant business). Now it gets even more complex, say your bill for service was $75, the insurance company says that their MAB for that service is $60, then they say out of that we will cover $45. Your job now is to write off $20 and try and collect the additional $15 from the patient (or secondary insurance if they have it) you are in breach of contract if you try to also collect the $20 which the insurance company said was not included in MAB. You may bill whatever you want, you will get paid what they say they will pay you!!! Your prices have nothing to do with what it cost to do business, it has to do with how much they will pay you.
Finally, secondary insurance. You may bill the remainder of the bill (not the $20 you wrote off mind you) to the secondary insurance if there is one. First you have to receive the report of payment from the insurance company, then you have to take a black marker and cross out all the peoples names on this report that are not part of this interaction, finally you must print a paper bill on what is known as a HCFA form and attach all of this together and mail it to the secondary insurance. Note, if you try to bill the patient for this amount when they have secondary insurance you are again, in breach of contract!!!! The time to bill and get paid for one 15 minute interaction in this manner is about 25 minutes for the billing and as much as 200 days to get paid (each ins co has 90, but you have to wait for that report before you can bill the second person and it takes time to dig up the information three months later). So for my $75 bill, for which I will only get paid $60, I had to wait the better part of a year, pay my billing person $11, and I spent money on postage twice, copying, printing etc. questions?

US Health Care, Lessons Learned.

In June of 2001 I graduated medical school almost a quarter of a million dollars in debt. With my education in mind and ideals in heart I headed out to complete residency. After residency I opened up my own practice in a small town (about three thousand people) with two ideals in my heart; 1. if I take care of the community, the community will take care of me 2. As a medical professional I am a resource to the community and as such, belong to it.I opened my practice on a shoe string budget (150K) and provided care to all people, bad insurance, no insurance, anyone who walked through my door. I scheduled patients such that I had time to truly address their problems (my dad always taught me that if you are going to do something you should do it right). Two years later I could only afford to pay myself $143/wk, none of my self pay patients were keeping up on their bargain to make regular payments (as low as $10/mo), the insurance companies administrative requirements were costing me more every month, and my liability insurance went up to $22,000 in the third year. Lesson 1, you cannot practice primary care with true integrity in the current atmosphere, you must either turn patients away or schedule so many that your quality of care becomes questionable (even to you). Lesson 2, my integrity is not more important than my family. I am not the only one who struggled I watched my family struggle because I tried to do what is right. I wrote my book with the belief that the only reason people would let this happen is that they don't understand how it works, I have yet to find a publisher for this unfortunate piece. I don't want to be rich, I don't want to be famous, I just want my faith in human nature and our brotherhood to be renewed by a population that won't let profit driven medicine neglect its members.

How Your Health Care Works, Part I

The point of writing a book about the health care in the US was to educate the population and, hopefully, in doing so motivate the population to advocate change. In light of the fact that the publication of my book to any public forum seems, well, unlikely, I thought I would start a series on my hardly read blog about how health care works. Because it took 200 pages to discuss this in my book I will have to give a more "readers digest" version here in my BLOG. Health care in the US is, in most cases, a business, granted there are community health centers and hospitals that operate with Govt subsidies and grants, the majority of the health care system in the US operates under a free market, capitalistic, business model. Accepting this as the basic rule, one must then first understand there is income and expense, that is it, this is basic. The way any medical practice works is the work performed by the doctor is the only work that generates income, everyone else in that office is an expense, the nurse, secretary, medical records, IT, maintenance, billing person, etc are all expenses supported by the work of the Doctor. On the income side, for the most part, the doctor only gets paid for face to face interaction with patients. There is no reimbursement for phone calls, lab interpretation, talking to consultants, talking to family members, script writing or calling, reading current medical literature, night calls from the hospital and so on, none of these crucial tasks generate income, they are generally non billable, and Medicare calls the "bundled services" that is, suppose I saw you in the office and prescribed a new medication, two days later you call me because you are having problems with it, I call back, we discuss the problem, I prescribe a new medication, and if I am good, I discuss the risks, benefits, costs and side effects of the new medication. Medicare considers the payment from the original visit to cover this interaction. There are billing codes for phone service, but non of the insurance companies include them in covered services, which means I would have to bill the patient, and, as you will see when I get to the specifics, this is not a small undertaking. So very basically the expenses of a medical practice are personnel (note nurses and billing personnel make from $17-$25/hr,) plus benefits, rent or lease, medical supplies, state, federal and board licensure fees, liability insurance, utilities, computer/software and of course my own pay. Income comes from insurance companies and patients. My practice cost approximately 20K a month to run and I kept a low overhead. I am happy to answer any questions at this point, or anywhere along the way.

Quality Health Care

A recent blog conversation on the topic of health care prompted me to remember a basic. The basic is, whenever you start to look at something to assess, understand and/or change you should first start by defining what it is you are talking about. Your next step, especially if you are planning on making changes, is to decide how you will measure change. In the case of health care it has historically been defined, in a society, by measuring infant mortality, life expectancy, immunization status, incidence of preventable diseases and several other "health stats". Having already developed a way to measure improvement, success or failure (god forbid). At this time I urge you to visit the world health organization web site and compare our health stats to those of other countries. As you will see, more money spent does not mean better over all health for the populace, at least not by these measures. Of course this becomes a very difficult and complex topic, what is basic health care? Is it fair to use health care dollars to pay for heart bypass surgery and breast implants?? I suppose if you were deformed from breast surgery or a burn it would be reasonable, but for shear sense of self? Think about it, if you have an infection should you have access (financially that is) to the newest antibiotic, no matter what the expense is? If we, as a society were to decide that basic health care should be provided to all, who would decide what "basic" is?? It seems obvious that immunizations would be basic, physical exams, etc, what about, say, erectile dysfunction, should our health care dollar pay for local erections?? (or elections for that matter). What if the reason you have trouble getting an erection has to do with diabetes or hypertension? what if you just want an erection like when you were young, who decides???? Think about it, I am not saying I have the answers, but I do understand the complexity of the question.

This is me..............without a tan!

Health Care propoganda

Please let me first say I am neither republican or democrat, which means despite the fact that I pay taxes I can not vote in the primaries, but it also means I have the freedom to express exactly what I believe without alienating a group to which I belong. Yesterday President Bush vetoed a bill that would expand children's health care in the United States citing, "Poor kids first," Bush said. "Secondly, I believe in private medicine, not the federal government running the health care system." I guess it is easy to believe in private medicine when you don't have to pay your own medical bills, you haven't lost a job because the cost of health care has lead to lay offs and you haven't lost a family member because you couldn't afford to pay for the needed care, this is what happens in private health care, make no mistake about it. Health care is a business, which means health care for those who can afford it, and damn the rest. If you think current govt programs are helping, let me enlighten you. If you are a medical practice that takes medicare you can expect to lose twenty cents on the dollar for every medicare patient, this means you can only afford to accept so many, in my community if you are on medicare or Medicaid you can expect to wait up to two months to be seen in a practice that accepts your crappy insurance, and when you are seen they wont have much time to see you because they have to see more patients to cover the cost of seeing you at all. When I was practicing (note that was only a year ago) I was the only one who accepted the Iraqi veterans insurance for about a 50 mile radius, because it paid so terribly none of the other practices would accept it. So let's keep going with the business of medicine such that the pharmaceutical industry, health insurance industry, liability insurance industry, and private hospitals can continue to get rich and the rest of us can die slowly, in pain, without the means for humane treatment or intervention. Thank you Mr. President!!!!!!!!!!!!

US Health Care

Having been a customer of the system and a person who did business within the system I am in a very unique position to see it from both sides. I can only wonder, however, why it is that the general population does not take a more active role to affect change. The "business" of medicine is just that, business. When you talk business you must talk, profit, loss and bottom line. There is little room for discussions about providing the most care to the most people, unless it is the most care to the most people with money. I once attended a class to get ready for the USMLE (united states medical licensing exam) where the professor spoke briefly about malaria, which kills millions of people a year, then he said "don't study malaria.................it doesn't kill anybody with money. Instead study Lyme disease which affects, not lethally mind you, about 1500 people a year." If you are under the illusion that a medical system run buy the private business sector is the best thing, get sick, get so sick that you lose your job (then of course your insurance), then give me a call as the bank is foreclosing your home and you have written off your life long savings to the hospital. This does not seem to be the way a civilized society should care for it's populace. For those of you who are afraid that allowing the government to rule the medical system, well, I am afraid too, but consider this, England, Canada, Switzerland, Germany and many others have a government controlled health care system and if you pole the people or the doctors they are quite satisfied...hmmmmmm...... I think the US government is at least as good as those governments, also we let our govt run; public education, medicare, the military, space exploration, agriculture and many other very important programs and we seem to be doing ok with those. Hmmmmmm? Your Thoughts?

Welcome

Welcome and thank you for taking the time to read my blog. This blog is really intended to be an open discussion about the current health care "non" system in the US. I am a doctor who went broke trying to provide health care in the current system, so I have plenty of stories. I also have written a book about it and am currently receiving my fifth or sixth publisher denial. Don't expect to read my book anytime soon!! The basic premise which I believe needs to be addressed is this. Health care can either be a right or a privilege, it does not survive trying to straddle the line, so if it is a privilege than the middle and lower classes can expect to be denied health care!! If it is a right then we need to remove it from the world of big business, health insurance, liability insurance and the pharmaceutical industry. Please post your thoughts on right or privilege and support your argument. One of the many lessons that practicing medicine brought to me was that the general population has very little insight into how the medical system works, thus the point of my book, if we are to make judgements about a system and/or move for change we must first know and understand it. I will answer questions about the system, medicine, or anything else that may fall under my expertise.