Now that I have taken a livelier role in the debate on health care and health care reform I have learned a great deal from the arguments of those who think a business model of medicine is the best cure. Knowing the arguments of both sides of any debate helps you understand not only the weaknesses of your own position (if you are open to it) but also the strengths and weaknesses of those who stand firmly in opposition.
It seems to me that one of the major arguments for pro-business medicine has been the constant finger pointing at government programs with all its bureaucracy, wasteful spending and the unintended consequences associated with such. These are good points, where the government has stepped in for health care; reimbursements are low, covered services are nonsensical, red tape is at the maximum, requirements are unbelievable and potential for abuse and waste is……well, more than potential but reality.
Upon pondering these points and reviewing the spirit of all the government health care programs that I know, the obvious and hardly mentioned point hit me. All government health care programs, right from the beginning and to date have been formulated for the sole purpose of patching holes in the business model! This is no example of government run health care, this is the government supporting in a rather covert way, business run health care. Medicare was formed because non of the insurance companies wanted to cover the elderly, they are a significant profit risk, Medicaid was for the poor that the insurance companies wouldn’t cover, EMTALA is for emergencies that the private hospitals otherwise wouldn’t provide care for, critical access hospitals are for the areas of the country where hospitals wouldn’t be profitable thus would not be built, HIPPA, COBRA, it goes on and on. Really what we are talking about is prop-ups and band-aides designed to fill the voids and gaps where a business model would have left a much greater portion of the American population “out in the cold” when it comes to health care.
I propose that if the government had not stepped in with band-aids and props the public would have revolted long ago for a more palatable health care system. In fact, despite the mass tragedy of it, I think we should tear off the band-aides and props let the system collapse and allow people to see what a business model of medical care really does. OK, that is too radical; on the other hand, nothing would move us forward faster.
One other point on "free market" medicine. By all accounts that I am aware of a market is defined by a group of people who would be interested in and be able to purchase a particular product. There is no "market" that I know of that includes all people when the product is both complex and moderately expensive. So, by nature and design "free market" medicine will leave out a substantial portion of the population. Who will care for these people? I suggest anyone interested try a little exercise, go to a crowded place and decide........say.........1 in 10 people do not deserve medical care because they are not defined by the market, then you decide who they should be.
Finally, if it is not obvious at this point, I would say that the current government band-aides are no example of what a government “run” system could or would do, if you want to see that take a look at the VA system (by most accounts, quite efficient and well run). My retort then is, “government run health care that you so strongly criticize is the only thing keeping your business model of medicine afloat, which, if it needs that much help obviously isn’t working and should be scrapped, let’s sit down, your side and mine, your arguments and mine and “design” a system that we can live with and benefits us all.”
Monday, March 17, 2008
Wednesday, March 12, 2008
Too Much Care
In a recent article in the NYT Dr. Sandeep Jauhar, here, discusses, quiet eloquently, some of the causes and effects of too much care. For further, more in depth reading on this topic I highly suggest Shannon Brownlee’s book “Over Treated”. I would like to go just a bit deeper into the subject.
The causes of too much care are vast and interrelated, however I do agree with Dr. Jauhar that the major cause is economic, having run my practice such that I minimized the amount of treatment and intervention, thus cost (thus further my profit) I suffered financially. I of course did this because it is what is in the best interest of the patient…….or is it? Dr. Jauhar’s cardiologist friend from Long Island took the other half of this argument. The justification is this, if I don’t make enough to continue to practice the community will actually lose an important commodity? In fact when I closed, 1500 patients were left without a doctor, and in a community with a shortage, many had to wait months to get one and had to travel much further away. I will leave it up to you, which is right, more care for survival of the practice such that care can continue to be provided (albeit at less quality), or proper care for the individual? Now, the eight main reasons we are getting too much care.
#1 ECONOMIC, That’s right, you are getting too much care because hospitals, and doctor’s offices can not sustain if they don’t provide these unnecessary, expensive and often dangerous treatments and interventions. The pharmaceutical industry on the other hand is providing this in the name of pure profit, survival is not an issue, not to say that some of the docs and hospitals are not specifically profit driven, but overall, less so.
#2 DEFENSIVE MEDICINE, Without a doubt defensive medicine is happening (that is ordering tests, and investigations not based on science or statistics, but based on, “just in case” or so “I don’t get sued”) the problem with this is that docs are often unwilling to admit (at lease publicly) how much of this that they do, thus there is absolutely no way to discern how much it is costing all of us. Read my piece on Liability here.
#3 MISPERCEPTIONS, The misperception that more care is better care, this “is” a misperception. The studies reveal that where there are more specialists and specialty care, life expectancy is shorter. Dr. Jauhar’s friend gives a nice example of how this affected the cost of medicine in his practice/community.
#4 PRIMARY CARE SHORTAGES, whether you think there is a shortage or not, there is. In many communities there is a long wait to get a doctor, and to get an appointment. This is tied tightly to economics, primary care gets reimbursed the least for what they do, thus if you own a practice or hospital you want to own some specialists and “encourage” your primary care providers to “provide less and refer more”!! With long hours, low pay, and often little respect, the number of medical students opting to go into primary care is ever shrinking. More specialty care obviously means more tests and more interventions.
#5 HEALTH INSURANCE, The health insurance industry adds nothing of quality to health care; they do however add overhead costs to the doctor’s office via, complex billing procedures and prior authorization requirements. Health Insurance companies spend 70-85% of premiums on health care; however that also means that 15-30 cents on the dollar of your money goes to CEO salaries and unneeded overhead expenses. With higher overhead, doctors and hospitals are forced to perform more expensive tests/procedures to pay the bills, more on overhead here.
#6 GOVERNMENT INTERVENTION/MANDATES, Yes, though I personally believe that a single payer system is the most equitable way to spend our health care dollar, I am not blind, it is clear that govt mandates on health care and insurance have increased the cost of providing care (in this profit system that means the cost of doing business) without providing means to pay for it. I have written at TPM café about this, read the section called band aides and props if you are interested, and if you can find it. Again, anything that increases the cost of doing business increases the likelihood of doing more expensive tests and procedures.
#7 MARKETING, That’s right, marketing increases what we spend on medical care, most notably through the pharmaceutical and medical device industry but this applies throughout. Of course more contact with the doctors and hospitals because the TV told you that you might have “blank” leads to testing, intervention and treatment. Without providing an incredibly detailed argument, if marketing did not increase income (in this case money spent on health care, meds etc) no one would do it.
#8 TOO MUCH CARE, more care begets more care, one abnormal test leads to another, leads to a complication which leads to an intervention which leads to…………
I was going to go into the effects; however, my usual verbosity has inspired me to shut up now. Please note however, that anyone who purports that it is only one or two of the above causes that leads to increased cost of health care, and or the increase in testing and overall decrease in quality of care is standing in the middle of a forest and blaming a single tree for getting them lost.
The causes of too much care are vast and interrelated, however I do agree with Dr. Jauhar that the major cause is economic, having run my practice such that I minimized the amount of treatment and intervention, thus cost (thus further my profit) I suffered financially. I of course did this because it is what is in the best interest of the patient…….or is it? Dr. Jauhar’s cardiologist friend from Long Island took the other half of this argument. The justification is this, if I don’t make enough to continue to practice the community will actually lose an important commodity? In fact when I closed, 1500 patients were left without a doctor, and in a community with a shortage, many had to wait months to get one and had to travel much further away. I will leave it up to you, which is right, more care for survival of the practice such that care can continue to be provided (albeit at less quality), or proper care for the individual? Now, the eight main reasons we are getting too much care.
#1 ECONOMIC, That’s right, you are getting too much care because hospitals, and doctor’s offices can not sustain if they don’t provide these unnecessary, expensive and often dangerous treatments and interventions. The pharmaceutical industry on the other hand is providing this in the name of pure profit, survival is not an issue, not to say that some of the docs and hospitals are not specifically profit driven, but overall, less so.
#2 DEFENSIVE MEDICINE, Without a doubt defensive medicine is happening (that is ordering tests, and investigations not based on science or statistics, but based on, “just in case” or so “I don’t get sued”) the problem with this is that docs are often unwilling to admit (at lease publicly) how much of this that they do, thus there is absolutely no way to discern how much it is costing all of us. Read my piece on Liability here.
#3 MISPERCEPTIONS, The misperception that more care is better care, this “is” a misperception. The studies reveal that where there are more specialists and specialty care, life expectancy is shorter. Dr. Jauhar’s friend gives a nice example of how this affected the cost of medicine in his practice/community.
#4 PRIMARY CARE SHORTAGES, whether you think there is a shortage or not, there is. In many communities there is a long wait to get a doctor, and to get an appointment. This is tied tightly to economics, primary care gets reimbursed the least for what they do, thus if you own a practice or hospital you want to own some specialists and “encourage” your primary care providers to “provide less and refer more”!! With long hours, low pay, and often little respect, the number of medical students opting to go into primary care is ever shrinking. More specialty care obviously means more tests and more interventions.
#5 HEALTH INSURANCE, The health insurance industry adds nothing of quality to health care; they do however add overhead costs to the doctor’s office via, complex billing procedures and prior authorization requirements. Health Insurance companies spend 70-85% of premiums on health care; however that also means that 15-30 cents on the dollar of your money goes to CEO salaries and unneeded overhead expenses. With higher overhead, doctors and hospitals are forced to perform more expensive tests/procedures to pay the bills, more on overhead here.
#6 GOVERNMENT INTERVENTION/MANDATES, Yes, though I personally believe that a single payer system is the most equitable way to spend our health care dollar, I am not blind, it is clear that govt mandates on health care and insurance have increased the cost of providing care (in this profit system that means the cost of doing business) without providing means to pay for it. I have written at TPM café about this, read the section called band aides and props if you are interested, and if you can find it. Again, anything that increases the cost of doing business increases the likelihood of doing more expensive tests and procedures.
#7 MARKETING, That’s right, marketing increases what we spend on medical care, most notably through the pharmaceutical and medical device industry but this applies throughout. Of course more contact with the doctors and hospitals because the TV told you that you might have “blank” leads to testing, intervention and treatment. Without providing an incredibly detailed argument, if marketing did not increase income (in this case money spent on health care, meds etc) no one would do it.
#8 TOO MUCH CARE, more care begets more care, one abnormal test leads to another, leads to a complication which leads to an intervention which leads to…………
I was going to go into the effects; however, my usual verbosity has inspired me to shut up now. Please note however, that anyone who purports that it is only one or two of the above causes that leads to increased cost of health care, and or the increase in testing and overall decrease in quality of care is standing in the middle of a forest and blaming a single tree for getting them lost.
Thursday, March 6, 2008
Just a little fun
Woody Allen
If only God would give me some clear sign! Like making a large deposit in my name in a Swiss bank.
If it turns out that there is a God, I don't think that he's evil. But the worst that you can say about him is that basically he's an underachiever.
I don't want to achieve immortality through my work... I want to achieve it through not dying
It seemed the world was divided into good and bad people. The good ones slept better... while the bad ones seemed to enjoy the waking hours much more.
Most of the time I don't have much fun. The rest of the time I don't have any fun at all.
My one regret in life is that I am not someone else.
When I was kidnapped, my parents snapped into action. They rented out my room.
You can live to be a hundred if you give up all the things that make you want to live to be a hundred.
George Carlin
Honesty may be the best policy, but it's important to remember that apparently, by elimination, dishonesty is the second-best policy.
I'm completely in favor of the separation of Church and State. My idea is that these two institutions screw us up enough on their own, so both of them together is certain death.
If it's true that our species is alone in the universe, then I'd have to say that the universe aimed rather low and settled for very little.
The very existence of flamethrowers proves that some time, somewhere, someone said to themselves, "You know, I want to set those people over there on fire, but I'm just not close enough to get the job done."
Well, if crime fighters fight crime and fire fighters fight fire, what do freedom fighters fight? They never mention that part to us, do they?
Bob Hope
A bank is a place that will lend you money if you can prove that you don't need it.
No one party can fool all of the people all of the time; that's why we have two parties.
If only God would give me some clear sign! Like making a large deposit in my name in a Swiss bank.
If it turns out that there is a God, I don't think that he's evil. But the worst that you can say about him is that basically he's an underachiever.
I don't want to achieve immortality through my work... I want to achieve it through not dying
It seemed the world was divided into good and bad people. The good ones slept better... while the bad ones seemed to enjoy the waking hours much more.
Most of the time I don't have much fun. The rest of the time I don't have any fun at all.
My one regret in life is that I am not someone else.
When I was kidnapped, my parents snapped into action. They rented out my room.
You can live to be a hundred if you give up all the things that make you want to live to be a hundred.
George Carlin
Honesty may be the best policy, but it's important to remember that apparently, by elimination, dishonesty is the second-best policy.
I'm completely in favor of the separation of Church and State. My idea is that these two institutions screw us up enough on their own, so both of them together is certain death.
If it's true that our species is alone in the universe, then I'd have to say that the universe aimed rather low and settled for very little.
The very existence of flamethrowers proves that some time, somewhere, someone said to themselves, "You know, I want to set those people over there on fire, but I'm just not close enough to get the job done."
Well, if crime fighters fight crime and fire fighters fight fire, what do freedom fighters fight? They never mention that part to us, do they?
Bob Hope
A bank is a place that will lend you money if you can prove that you don't need it.
No one party can fool all of the people all of the time; that's why we have two parties.
Wednesday, March 5, 2008
Liability Insurance
Let’s talk Liability. I know, I know, ughhhh! But truly, medical malpractice insurance serves a very particular purpose. It protects those of us in the field of medicine from losing everything due to a costly mistake, or maybe not…….I’ll get back to that. For perspective I will give you my specific costs. When I opened my practice (keep in mind I did do obstetrics) the medical liability Insurance company that I spoke to gave me the following quote, it will be 5K for the first year, then it will go up 5K a year for five years, after which it should level off. Huh? The explanation goes like this, in order to make a big enough mistake to get sued you have to actually see patients, the more you see, the greater your risk. So it makes sense that there should be an initial steep incline. Ok I said, can’t practice without it, well, in my state you can legally but you wont get hospital privileges, nor will any of the health insurance companies allow you to become a “preferred provider” whatever that means. So I did my projections and budget and was all set, by the way, my projections where so close to what I actually made in the second year it was scary, I was within $20!! But, then the dreaded third year began, anticipating my bill for 15K I opened the envelope only to find a bill for 22K!!!! What?! I called my broker who then reported that the state insurance commissioner had allowed a 17% increase in premiums. What? Why? Has there been a rash of malpractice suits with massive payoffs? ….no. So I proceeded to call and email and call the state insurance commissioner, funny I never did get an answer. At this point I had to take a loan to finance my liability insurance. Can you believe that? So now I was paying interest on this increase. Not long after this I closed my practice (four months to be exact).
I would like to break this down just a bit. First of all, let’s remember that insurance companies are publicly owned and traded, thus by law they are responsible to their stock holders, not their customers (I don’t think I will ever understand that). Next we need to remember that a major portion of their income is received via investments made with those premiums, rather than the premiums alone. So what is the cause of the cost and “Liability Insurance Crisis”? Depends on who you talk to, if you talk to Doctors you will here that we need “Tort Reform” because greedy lawyers and large payouts, I suppose if you talk to lawyers they will say careless doctors are the cause, and if you talk to economists the answer will be poor performing stocks. The economists will add, however that the price will continue to rise as long as the market can handle it, think of it, if you are selling widgets and you are charging three dollars, and raise the price to six and people keep buying it, why not go up. Free market should bring this down right? Maybe, if you raise your prices and increase your pay outs to stock holders, wont other insurance company stock holders be jealous, and raise their prices? It is a tedious balance to say the least. But let me tell you, as a Doctor we don’t shop around that often and we sign for a year at a time, so….they are pretty safe with my premiums for a year. One of the reasons we don’t shop around is a little thing called “tail”, what? Most of today’s medical liability insurance is a “claims made” policy, that is you are covered for claims made while the policy is in effect, when you are done or want to change policies you will have to buy tail coverage for anything that happens later, i.e. if I missed breast cancer during an annual exam, after which I cancelled my insurance, then three years later the patient finds out she has breast cancer and decides to sue me, even though I was covered when I examined her, I am not covered now, unless I bought “tail”, incidentally the bill for my tail coverage after a mere 2 ½ years of practice was $53,000.00!!!!!!!! This, among other things provides market stability, if you want to change insurance companies you better have a few bucks saved up. By the way, I didn’t buy the tail, so if a law suit comes up latter I can lose everything I have, kids college fund, house, car, etc. etc.
Now, let’s talk a little about Tort reform, this basically means let’s make laws that A. make it harder to sue, and B. decrease pay outs when a law suit does go through. Sounds like it will help right? Nope, In the states that have passed tort reform (NH, ME, TX, among others) there has been no change in premiums whatsoever. So why are docs screaming for tort reform? Look at the share holders, presidents, board of trustees and CEOs of many of these liability insurance companies, I looked at the top six, this group is filled with Doctors!!!!!!!!!!!! Talk about a conflict of interest. Tort reform is good for insurance company profits and bad for people wronged by the system (probably bad for trial lawyers as well).
Now back to my “mistake” here is how it actually works, medical malpractice law suits are decided by juries and usually it is an emotional decision (that is why obstetrics fares so poorly, “everybody deserves a healthy baby”) also based on “standard of care” not based on evidence or science. So as a professional I must make decisions with you in your best interest based on science, but if that is in conflict with “standard of care” I am at risk, and if it goes to court, at fault. Here is an example, all the current evidence reveals that the use of a PSA test (for prostate cancer) is a poor screening tool and not only does in not change outcome, it may actually cause harm, however, because it is standard of care, if I don’t order one, then you end up with prostate cancer, you can sue me and win!.
Finally, I would like to mention the disempowerment that having liability insurance creates. Not only do I have no control over the premiums, nor can I practice without it, but if I get sued they decide whether or not to actually fight the suit. So, if it is financially equitable to settle out of court, that is what they will do, without regard to my good name or reputation!!! I was going to quote some of their profits, investments, payouts etc, but this got long winded, and this info is available online, just google it and look for annual reports.
I would like to break this down just a bit. First of all, let’s remember that insurance companies are publicly owned and traded, thus by law they are responsible to their stock holders, not their customers (I don’t think I will ever understand that). Next we need to remember that a major portion of their income is received via investments made with those premiums, rather than the premiums alone. So what is the cause of the cost and “Liability Insurance Crisis”? Depends on who you talk to, if you talk to Doctors you will here that we need “Tort Reform” because greedy lawyers and large payouts, I suppose if you talk to lawyers they will say careless doctors are the cause, and if you talk to economists the answer will be poor performing stocks. The economists will add, however that the price will continue to rise as long as the market can handle it, think of it, if you are selling widgets and you are charging three dollars, and raise the price to six and people keep buying it, why not go up. Free market should bring this down right? Maybe, if you raise your prices and increase your pay outs to stock holders, wont other insurance company stock holders be jealous, and raise their prices? It is a tedious balance to say the least. But let me tell you, as a Doctor we don’t shop around that often and we sign for a year at a time, so….they are pretty safe with my premiums for a year. One of the reasons we don’t shop around is a little thing called “tail”, what? Most of today’s medical liability insurance is a “claims made” policy, that is you are covered for claims made while the policy is in effect, when you are done or want to change policies you will have to buy tail coverage for anything that happens later, i.e. if I missed breast cancer during an annual exam, after which I cancelled my insurance, then three years later the patient finds out she has breast cancer and decides to sue me, even though I was covered when I examined her, I am not covered now, unless I bought “tail”, incidentally the bill for my tail coverage after a mere 2 ½ years of practice was $53,000.00!!!!!!!! This, among other things provides market stability, if you want to change insurance companies you better have a few bucks saved up. By the way, I didn’t buy the tail, so if a law suit comes up latter I can lose everything I have, kids college fund, house, car, etc. etc.
Now, let’s talk a little about Tort reform, this basically means let’s make laws that A. make it harder to sue, and B. decrease pay outs when a law suit does go through. Sounds like it will help right? Nope, In the states that have passed tort reform (NH, ME, TX, among others) there has been no change in premiums whatsoever. So why are docs screaming for tort reform? Look at the share holders, presidents, board of trustees and CEOs of many of these liability insurance companies, I looked at the top six, this group is filled with Doctors!!!!!!!!!!!! Talk about a conflict of interest. Tort reform is good for insurance company profits and bad for people wronged by the system (probably bad for trial lawyers as well).
Now back to my “mistake” here is how it actually works, medical malpractice law suits are decided by juries and usually it is an emotional decision (that is why obstetrics fares so poorly, “everybody deserves a healthy baby”) also based on “standard of care” not based on evidence or science. So as a professional I must make decisions with you in your best interest based on science, but if that is in conflict with “standard of care” I am at risk, and if it goes to court, at fault. Here is an example, all the current evidence reveals that the use of a PSA test (for prostate cancer) is a poor screening tool and not only does in not change outcome, it may actually cause harm, however, because it is standard of care, if I don’t order one, then you end up with prostate cancer, you can sue me and win!.
Finally, I would like to mention the disempowerment that having liability insurance creates. Not only do I have no control over the premiums, nor can I practice without it, but if I get sued they decide whether or not to actually fight the suit. So, if it is financially equitable to settle out of court, that is what they will do, without regard to my good name or reputation!!! I was going to quote some of their profits, investments, payouts etc, but this got long winded, and this info is available online, just google it and look for annual reports.
I'm Back
This is a short post to inform my readers (if there are any) that I am back. Over the last several months the love of my life and I were blessed with a baby boy, and, well he is a pain in the butt. We haven't slept much, slept together or seen each other much trying to juggle work, the other children, fair sleep and the cranky baby!!!
I would like to take a moment to note that I have made some changes and intend to post more regularly. I am looking for a dialogue, not a monologue. I hope for meaningful interaction, and though occasionally agressive I have no issue with having my beliefs challanged, this is how I learn, change and grow. So, let the games begin.
I would like to take a moment to note that I have made some changes and intend to post more regularly. I am looking for a dialogue, not a monologue. I hope for meaningful interaction, and though occasionally agressive I have no issue with having my beliefs challanged, this is how I learn, change and grow. So, let the games begin.
Friday, November 2, 2007
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!!!
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!!!
Thursday, October 25, 2007
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?
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?
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