Stanley Feld M.D.,FACP,MACE

The AMA House of Delegates met and developed policy recommendations concerning the In Store Clinics. They stated they were not opposed to the in store clinics. However they wanted certain quality criteria met. I do not believe that the healthcare insurance industry relies on the AMA policy making meetings to help them determine who and what they will pay for what services these in store clinics provide. Its only concern is that the patient gets treated at the lowest price and permits the healthcare insurance industry to retain its control of the healthcare system
The AMA press release contained the following statements;

“Patients want quick and easy access to health care services, but they shouldn’t have to worry about the safety and quality of care provided in these clinics, said Rebecca J. Patchin, MD, AMA Board Member.”

Implicit in the AMA’s statement is that the in-store clinics have the ability to provide quick and easy access to healthcare services, while the practicing physician’s office can not. The only objection the AMA has is that the treatment might not be safe and the quality might be poor.

“Physicians deliberating the new principles at the AMA’s policy-making meeting agreed with the public’s concerns, noting that intensive diagnosis and care should not be carried out at clinics staffed by less-qualified health professionals and equipped for basic services. Physicians added that health care safety could be negatively affected if in-store clinics lead to fragmentation of patient care, inadequate follow-up and missed opportunities for preventive care of patients.”

“To enhance public confidence in the quality of care provided by store-based clinics, the AMA adopted the following principles to help promote their safe and effective operation.”

• Store-based health clinics must have a well-defined and limited scope of clinical services, consistent with state scope of practice laws.
• Store-based health clinics must use standardized medical protocols derived from evidence-based practice guidelines to insure patient safety and quality of care.
• Store-based health clinics must establish arrangements by which their health care practitioners have direct access to and supervision by those with medical degrees (MD and DO) as consistent with state laws.
• Store-based health clinics must establish protocols for ensuring continuity of care with practicing physicians within the local community.
• Store-based health clinics must establish a referral system with physician practices or other facilities for appropriate treatment if the patient’s conditions or symptoms are beyond the scope of services provided by the clinic.
• Store-based health clinics must clearly inform patients in advance of the qualifications of the health care practitioners who are providing care, as well as any limitation in the types of illnesses that can be diagnosed and treated.
• Store-based health clinics must establish appropriate sanitation and hygienic guidelines and facilities to insure the safety of patients.
• Store-based health clinics should be encouraged to use electronic health records as a means of communicating patient information and facilitating continuity of care.
• Store-based health clinics should encourage patients to establish care with a primary care physician to ensure continuity of care.
Who is going to administer and enforce these rules? No one. Who cares about these rules? No one. The patients using these in store clinics should care about the rules and demand that the local governments administer and enforces these rules.

“There are clear incentives for employers, health insurers, and retailers to participate in the implementation and operation of store-based health clinics. Employers and insurers report being able to contain health care costs by using in-store clinics, while retailers state that the clinics help increase store traffic and drive sales.”
“The new AMA principles will help ensure these incentives do not override the basic obligation of store-based clinics to provide patients with quality care, said Dr. Patchin an AMA board member .”

The CCA responded to the AMA’s principles to promote in store clinic safe and effective operation with the following press releases.

“Responding to an American Medical Association resolution regarding retail pharmacy-based clinics, Tine Hansen-Turton, executive director of the Convenient Care Association, released a simple statement: “If it’s broken, fix it.”

Everyone agrees the healthcare system is broken. The CCA and the in store clinics are marching to the front of the line to fix it. Did the AMA march to the front of the line to fix the healthcare system? No. The Convenient Care Association has captured the healthcare repair initiative. The AMA has been idle and then reactive.

Hansen-Burton continued, “Convenient care clinics have proliferated in retail settings throughout the country due to a widespread lack of access to high-quality, affordable health care in America.
There has been a perception among consumers that there is a widespread lack of access to high quality, affordable health care in America.”

Americans love people and companies that are innovative and visionary. Americans certainly agree that we need an innovative and visionary model of healthcare to repair the broken system. Has medical practices or organized medicine provided them? It is the perception of most Americans that American medicine has not provided an innovative and visionary model.

“ Convenient care clinics collectively boast a 98 percent patient satisfaction rate, which indicates that Americans have embraced this innovative and visionary model of health care.”

I would like to see CCA’s evidence for a 98% approval rating for their care. I would also like to see how Americans have embraced the services of CCA members. It sounds like hype to me and a well crafted public relations campaign.

The AMA quotes a Harris Interactive poll that had a different conclusion.
“According to a Harris Interactive poll, while 78 percent of the public believes that store-based health clinics could provide a fast and easy way to receive basic medical services, 75 percent raised concerns about the quality of care these clinics provide. The vast majority of respondents were also apprehensive about staff qualifications in a clinic not run by medical doctors.”

CCA’s press release goes on to say;

“While the AMA convened its annual meeting this week to discuss ways to prevent patient access to convenient health care, the CCA held an annual retreat to promote accessible, affordable, price-transparent health care to all Americans.”

The above causes one to think the CCA is proactive and innovative while the AMA is defensive and reactive. In our sound bite society the CCA would win even though the organization is only eight months old and represents only sixteen corporate companys’ interests. In reality these corporate interests true concern is to profit from the 2 trillion dollars spent in the healthcare system.

The big question remains. Is the care provided good medical care by people capable and qualified to provide good medical care?
Who should be the judge of good safe medical care?

Walgreen Co. spokesman Michael Polzin stated in response that AMA members were more likely to find out “that that legislators and constituents have been demanding accessible, affordable and high-quality health care for years and that’s what retail clinics are delivering.”
The in-store clinics claim they are simply responding to what legislators and constituents were demanding for years. The assumption that they would be providing high quality health care is simply an assumption. No one has adequately defined high quality health care and CCA has not proven that the in store clinics deliver quality care. CCA simply declares that they deliver quality care.

“The CCA partners with all health care providers, including physicians,” Hansen-Turton said. “We are surprised that the AMA would take the position that it has because so many physicians and other health care professionals have accepted this new model and see it as part of the solution to our broken health care system.

Where is the evidence that physicians and other healthcare professionals have accepted this new model and see it as part of the solution to our broken health care system? I have not been able to find the evidence for this statement. Physicians who participate in the in-store clinics by signing off on the nurse practitioners and physician assistants work as figureheads. They do not know the patient or the patient’s illness. The physician’s actions cannot be interpreted as confirmation of quality medical care.

Carl Sandburg said in the Prairie Years “If you tell a lie enough times it becomes the truth.
The problem is a liar has to have a good memory.”

The executive director of CCA then goes on to scold the AMA for its position on the in store clinics.
“The AMA and CCA should be working together on solutions to improve our health care system’s efficiency and effectiveness. America has embraced the services that CCA members are providing as part of the solution, and we invite the AMA to recognize the role clinics provide in offering access to affordable, high-quality, basic health care services to all individuals.”

Carl Sandburg is right. The goal is to keep repeating the same unsubstantiated statement over and over again until it becomes the truth. In 2007 this tactic is called spin.

I believe these clinics will fail because they will not be able to generate a positive cash flow from these clinics. Perhaps the pharmacies and big box store want them as loss leaders. Rite Aid closed their in store clinics in Portland after one year.

I believe it is organized medicine’s responsibility to develop programs to teach physicians to service patients in need of basic health care services more efficiently. Physician practices must provide affordable, high quality, medical care services to patients. The medical profession must change the publics perception of physicians’ practices.
The only thing I can say to patients at the moment about in store clinics is
Let the buyer beware!!

Stanley Feld M.D.,FACP,MACE

I believe in-store clinics are a bad idea and they will fail. If successful these clinics can potentially put family practitioners out of business. If they are marginal, they will put a reasonable dent in the primary care physician’s ability to make a living. It is presently difficult for family practitioners to make a decent living. The development of in-store clinics is the result of the difficulties patients are having with affordable access to medical care. If patients have to go to the emergency room of a hospital, wait three hours to be seen, and incur a large bill for a simple illness the healthcare system is not being responsive to the patients’ needs. Convenient Care Clinics’ attraction to patients is they help them avoid these barriers to care.

The growth of these in-store clinics is the result of the primary care physicians’ (PCPs’) inability to set up their medical practices to match the needs and schedules of the hectic life of patients in America today. The blame should not only fall on the PCP. The blame should also fall on organized medicine’s inability to recognize and respond to the needs of the PCPs’ and the practicing physicians’ patients. Organized medicine should be developing programs to teach PCPs how to respond to the changing needs of patients’. If medical practices do not respond to the needs of their patients, someone will.

A problem with the in-store clinics is they are run by nurse practitioners or physician assistants. They are not under the direct supervision of physicians. For years, physicians have fought to prevent physician extenders from practicing medicine on their own for the protection of patients. Some in-store clinics will have a physician sign off on the medical care provided. However, the physicians will not have had contact with the patient or examined the patient. Most of the time the in-store clinics can get away with this level of care. This type of care cannot be defined as quality medical care. Hopefully the nurse practitioner or physician assistant will recognize a really sick patient. Hopefully, when they do they will send the patient to the nearest emergency room.

I believe the in-store clinics will have a difficult time achieving positive cash flow unless they raise their prices or do more in-store procedures. The financial experience of hospitals that opened DOC in the Boxes to feed their hospitals was disastrous. I predicted a decade ago that it will only be a matter of time before the hospital DOC in the Boxes would go out of business. Many physicians who started these clinics did well monetarily when they sold their DOC in the Boxes to hospital systems. It might be that the pharmacies (CVS, Target, Walgreens, and Wal-Mart) are hoping to make money when the patients are in the stores. Rite-Aid has already closed their in-store clinics in Portland Oregon.

In October 2006 a trade association for these in-store clinics was founded to lobby for insurance payments and other interests. The Convenient Care Association is a nonprofit organization representing health care facilities that provide routine, non-emergency services to walk-in patients at pharmacies.

The goal of the association is to help the in-store clinic learn to profit from acute convenient medical care. The CCA is an association of convenient care clinics that provide accessible, affordable, quality health care throughout the United States. Convenient Care Clinics (CCCs) are being launched across the country to help provide care to meet the basic health needs of the public. These health care clinics, located in convenient locations accessible to the public, are primarily staffed by advanced practice nurses, including nurse practitioners (NPs) and clinical nurse specialists (CNS). They may also be staffed by physician assistants (PAs), and/or physicians (MD or DO). CCA states; “Health care driven by the needs of the patient is at the heart and soul of the Convenient Care movement. “

It looks like the CCA has captured the high road for sound bites. The statement that healthcare is driven by the needs of the patient is at the heart and soul of the convenient care movement is a very powerful statement. It assumes that medical practices have failed. Their statement is in contrast to the public’s perception of non user friendly medical professional clinics.

I have recently received several comments from patients who were examined and blood tested in their physician’s office. The results of the examinations were called to the patients by the physician nurses. The nurses told the patients the results and physicians’ recommendations for specific treatments. One person asked to speak to the physician. She was told she had to make another appointment with the physician. The recommendation was to start a statin. The patient was afraid of the side effects of the statin. The nurse was going to call in the prescription. The writer stated “ so much for your emphasis in your blog has been on the importance of the patient physician relationship.”
“This encounter does not speak well for the patient physician relationship.” I must say the patient was correct. My hope is this is an infrequent occurrence.

Members of CCA are ATLANTICARE HEALTHRITE, AURORA QUICKCARE, CAREWORKS CONVENIENT HEALTHCARE, CHECKUPS, EARLY SOLUTIONS CLINIC, SMARTCARE FAMILY MEDICAL CENTERS, LINDORA HEALTH CLINIC, MEDPOINT EXPRESS, MEDBASICS, MY HEALTHY ACCESS, QUICKHEALTH, REDICLINIC, SUTTER EXPRESS CARE, TAKE CARE HEALTH SYSTEMS, TARGET CLINIC, THE LITTLE CLINIC, plus a large number of pharmaceutical companies.

You will notice the in store clinics are run by business people and corporations. They are not run by physicians. The primary goal is to make money. The vehicle is providing care that the primary care physician should be delivering.

The AMA in its June meeting passed a policy resolution concerning in store clinics:
“With quick clinics opening in chain stores across America staffed by nurse practitioners and physician assistants, the AMA House of Delegates made clear during the Association’s Annual Meeting that, while it’s not against the facilities in principle, it believes they are no substitute for a long-term relationship with a doctor.”

If the consumer’s clinical experience with the medical profession is negative one and CCA publicizes that its health care is driven by the needs of the patient and those needs is at the heart and soul at the in-store clinics, and you are a patient in need of convenient care, which would you choose?

If CCA’s claims were true, the answer to the question is obvious. CCA sponsored by the corporations listed is in the midst of a huge public relations campaign and media blitz to capture the hearts and minds of the public. CCA’s campaign is clever and might be extremely effective. Everyone loves the underdog, the David who is going to slay the Goliath (the AMA). CCA’s sound bites are perfect for our sound bite society. It looks as if CCA has caught the AMA flatfooted. The AMA’s response has seemed anemic so far.

Stanley Feld M.D.,FACP,MACE

This is another in my series of stories about my childhood. You could guess that I am baseball nut. I was also a pretty good baseball player. I guess it was the result of watching all those New York Yankees and New York Giants games. I made the William Howard Taft baseball team. This is one of my baseball stories.

We were playing Cardinal Hayes High School at McCombs Field in the shadow of Yankee Stadium. This was the first or second game of the season. Cardinal Hayes is a well known catholic school in the Bronx. It always seemed to me that the guys on the Cardinal Hayes team looked bigger and stronger than we did. Someone told me they were a year older than us.

I am a lefty and therefore played first base. The only other position they put lefties in those days was right field. I always had the impression that the worst guy on the team was put in right field. I chose first base and turned out to be a pretty good first baseman.

It was a beautiful spring day and we were all excited to get the game started. Cardinal Hayes was designated the home team so Taft High School batted first. Being lefty, I batted second. SM our 5’4” 130 lb. centerfielder batted first.

The Cardinal Hayes pitcher was a very tall guy (about 6’4”). He looked like a giant on the mound. SM and I were in the batters circle warming up for our at bat. I noticed the big tall guy was fast but he couldn’t get a pitch over the plate.

I told SM to be careful because this guy was wild as hell. He assured me not to worry. Anyway the first pitch went right at SM and hit him in the head. We did not have helmets in those days. SM was unconscious and the ambulance was called.

It frightened the heck out of me. I had already made my mind up on how I was going to handle myself with this pitcher. Our coach HL knew me well. He had an idea how I was going to handle myself.

I was a pretty smart kid, actually within the top 1% of my class. My father had already decided my career path. He told me I could do anything I wanted to do as long as I became a doctor. It was settled. I had to strike out quickly and not give this pitcher a chance to hit me in the head.

If I got hit in the head there goes medical school. He could knock my brains out. I knew I could not disappoint my father. He would kill me. My strategy was set. I would swing at the first three pitches no matter where they were. HL, our, coach read my mind. He came running out of the dugout as I was approaching the batters box. There was a three quarter hour delay of the game in order to get SM to the hospital. I had plenty of time to think. HL came running up to me and shouted, “Stanley I want you to keep you head in there.” The last thing I was going to do was keep my head in there and HL knew it.

I had already concluded that I was going to blow this at bat. This guy would be out of there by the time I was at bat again. Needless to say, I had trouble getting out of the way of four wild pitches. They were so wild I did not have a chance to swing and miss. To my luck and my baseball career he walked me on four straight pitches. It disrupted my strategy. All I wanted to do was get safely into the dugout.

It turned out the 6’4” Cardinal High School pitcher walked the next two batters and was taken out of the game by his coach. We went on to score three runs and win the game despite their size and strength. It was not because we were so great. We just stuck in there even though we did not want to.

The lesson to be learned is never put you head in front of a fast ball. The healthcare system lesson to be learned from this story is even though they (the healthcare insurance industry) are bigger, more powerful and stronger you need to stick in there and do the right thing.

Remember there would be no healthcare system without the primary stakeholders, the patient and the physician.

Stanley Feld M.D.,FACP,MACE

Medicare Part D is the drug benefit insurance for Medicare recipients.
The government constructed a program where the healthcare insurance industry sells insurance to provide prescription drug coverage.

There are various plans available from various healthcare insurance companies charging various prices. The healthcare insurance industry would call it competitive pricing. However, without real price transparency, multiple pricing is meaningless. The real important price is the price the patient is charged against his doughnut verses the price the healthcare insurance company pays the pharmacist. The various plans are confusing, to say the least. The plan outlines have been standardized by the government. The prices for the various healthcare companies’ plans have not been standardized.

If we drill down deeper, the price the healthcare insurance company pays the pharmacy has not been standardized. The industry negotiates that price with the various pharmacy chains. The price the healthcare insurance company charges the patient is applied against the patient’s doughnut. The patients’ doughnut (coverage gap) kicks in after the patient purchases $2200.00 of drugs. Therefore, the higher the price the healthcare insurance company charges the patient’s account for a medication the faster the patient hits the doughnut and the faster the patient pays full price for the medication. The price the healthcare insurance company applies to the patient’s doughnut has nothing to do with the price the healthcare insurance company paid the pharmacy for the drug. This is the place the fairness to the patient breaks down. Many seniors who have purchased these plans, in order to feel financially secure, are now discovering the deception in these various Medicare Part D plans.

Richard Jellicoe writes; “I have Medicare Part D from AARP. UnitedHealthcare
is the carrier. UnitedHealthcare offer drugs with co-pay almost twice what I can get the same drug via cash. I guess that is how UnitedHealthcare can pay its fired CEO $5 million a year in retirement.”

He goes on to say:“What amazes me is that AARP endorsed this company when it was time for 2007 Medicare sign up and it was not till many months later that AARP acknowledged that it’s endorsement of UnitedHealth care was a paid endorsement. And AARP is supposed to help the seniors.”

Consumers can not assume the government will protect them. It has not in the past. You can not assume that organizations like AARP who advertise that they will protect you will protect you. Consumers must become sophisticated buyers of healthcare products. Consumers have trained themselves to become sophisticated buyers of other products such as automobiles, electronics, food, clothing, and housing. They have learned to receive good value and have created competition among vendors for their dollars.
The healthcare insurance industry continually says that consumers are not capable of dealing with healthcare pricing. If you think about it our most precious possession is our health. We should be most responsible for our health and the price we pay to maintain it. I know consumers can be very smart about healthcare consumption if they owned their healthcare dollar.

Mr. Jellicoe goes on to say “I have been reading everything I can find on UnitedHealth Care. I have been amazed on how those in the know understand the lack of ethics at this company. The thought of 90% of Nevada being under the control of this corrupt company frankly scares me to death.”

Mr Jellicoe, you have defined a monopoly. Our government is supposed to be working for us and not for the healthcare insurance industry. Consumers have to demand that our government does something about your complaint. The problem is most consumers are not aware of these abuses. Our sources of information (mass media) do not provide detailed information. Detailed information does not hold our attention and attract advertisement revenue. We are an inpatient, sound bite society seeking sensational stories. However we become very concerned when an issue affects us directly. The broken healthcare system is directly affecting us all now. I believe as a people we are very smart. We are starting to demand a solution. However, the government has put the fox in the hen house to protect the hens. The hens will not be protected.
One of the reasons I am writing this blog is to try to get the people who are not sick to pay attention to what is going on. The healthcare system needs to be fixed before we get sick and need medical care and medical drug benefits.

Many years ago a well connected patient of mine was an advisor to several U.S. Presidents. He was working on stopping drug trafficking to the United States from Mexico and South America. Hundreds of millions of dollars was laundered through Miami banks. His assignment was to convince the banks to stop laundering drug money. One day I asked him why congress doesn’t just pass a law revoking the banking permits.
In his frustration, he said “most people do not know what they vote for. They do not express their opinions to how their congresspersons should vote in congress.” He said the law could not be passed because of the banking lobbys’ influence in congress. He also said” we as a people get what we deserve. We have the right to demand the appropriate action. We do not exercise that right. Until we start paying attention to what is going on and get rid of the politicians who do not do what is right out of power nothing will change”.

“All of the news in the press is about unimportant issues. Th “news” is a distractions from the real needs of the people. None of the important issues are covered in detail so that we rarely know the real issues. “

It is important to notice that the only easy way Mr. Richard Jellicoe can express his frustration is through the new media, the blogosphere. Will the new media be effective? I hope it will. Americans’ are not a stupid people. Our freedom of speech is precious. Social networking of a concerned population will change the paradigm of healthcare insurance to a consumer driven healthcare paradigm.

Stanley Feld M.D., FACP, MACE

Michael O’Grady of Grosse Pointe Farms, MI expresses the mistrust between the employers and the healthcare insurance industry much better than I can. He also confirmed for me that people on the internet are not only thinking about the problem of healthcare and what I am saying but are upset about the terrible things that are going on in the healthcare industry.

“I must comment on two key components of the healthcare system I felt were blatantly missing from your blog. ”

“The first was in your list of stake holders. No where to be found are the employer groups who actually fund most of the health care in this country.”

At the time I received Michael’s comment he was correct. I was concentrating on how the 46.7 million uninsured can be insured. The key answer is for employers to be able to provide tax deductible funds to their employees in order for the employees to purchase their own healthcare insurance policy with their own money. If an employee chooses not to buy healthcare insurance he does not get the money.

This maneuver accomplishes three things. First, it gets the employer out of the healthcare insurance loop. Employers may stay in the loop if they think they can protect their employees. Second, the employee relieves the employer of the burden of negotiating a premium at a tremendous disadvantage. Employers have noticed that they have be less than effective in keeping premium cost down in recent years as expressed by EC previously. Third, it puts the patient in charge of his healthcare dollar. This creates a huge buyer pool and forces the healthcare insurance companies to develop innovative and cost effective products. If they do not become efficient, someone will come along and take away the business.

Unemployed or self employed consumers can buy healthcare insurance with pre-tax dollars. This level playing field does not exist today. A self employed or unemployed person must be able buy insurance with after tax dollars. Notice that this simple change in the tax law would weaken the healthcare insurance industries hold on healthcare and force them to compete for the healthcare insurance dollar.

President Bush has called for this tax reform. However, there has been no follow-up. It seems he has backed off. Congress has no interest in passing this logical law that could help cure the uninsured problem. It would be putting power in the hands of the consumer. It has been opposed by the healthcare insurance companies lobbying effort. The evaluation of the Congressional Budget Office seems to point to a positive outcome when read in detail.

“Although you appear to have many good ideas, and are a proponent of changing many of the necessary evils of the broken health care system, you are in fact a stake holder.”

Michael, I am presently a consumer stakeholder. I retired from an excellent practice of Clinical Endocrinology in order to devote adequate time to help repair the healthcare system for the benefit of the consumer and the survival of the patient physician relationship. I believe the patient physician relationship is a critical therapeutic element in the care of sick patients. Making medical care a commodity will destroy medical care in this country.

“The employers are the one in the end who actually foot the bill for most of the health spend in the U.S. The unfortunate circumstance is they are being led blindly down the path of excessive baggage by consultants and their partners, who we refer to as BUCA (Blues, United, CIGNA, and Aetna).”

Michael, you are correct. The large employers have human resource officers whose responsibility is to choose the correct healthcare insurance plan for its employees. The BUCA have learned to manipulate and confuse the human resource officers. It gets back to the old question: would you let your human resource officer, or insurance company purchase your food, your clothing or your car? You might let the HR person negotiate for you. However you are the owner of the purchase and would be responsible for the choice. Your unwillingness to let the HR person negotiate for you would increase if the purchases became more confusing and unsatisfactory. You would want control.

The seller (healthcare insurance company) is motivated in the present system to confuse the HR officers. The seller also has the advantage because the number of people in a single company is small compared to the total number of people in society as a whole. The key to repair is to motivate the seller to compete. In a real price transparent environment the healthcare insurance industry would be competing for customers. All the necessary changes would have to occur at the same time for it to be effective.

“The second piece I felt that was missing was the reimbursement methodology in place today prevents any fix of the health care system. The PPO discount system is a disaster and adds between four to six billion unnecessary dollars to the health care system each year. These are dollars employer groups are paying to the BUCA’s and PPO networks in access fees each year, to provide provider discounts. Twenty years ago there may have been a value to an employer group to receive discounts in exchange for steering patients. There may have been a value to a provider to provide discounts in exchange for steerage. These days are over, and retail is for suckers.”

Michael, you are right on target. No one pays retail unless they want to. The reason Sam Walton went from a bloomer salesman to the largest department store on the globe is because he learned how to provide the best price with a good quality product to the consumer . Consumers figured out which price and product was best for them.

“So why should employers pay four to six billion a year for what really amounts to retail pricing? Transparency? Does it matter if a provider makes transparent their charge master? Each network or carrier has their own deal with each provider that is considered proprietary. What is being charged by the provider is irrelevant, thus making any HSA plan doomed to failure.”

Price transparency is bogus in healthcare lingo presently. The automobile industry is getting close to real price transparency. They are not there yet. The electronic industry is close with organizations like c/net.com and simonsays.com. The consumer is not stupid. When they are in control or their healthcare dollar they will force real price transparency. Actually, they are getting smarter each day.

“A new reimbursement methodology needs to be adopted. This new methodology needs to be developed in partnership with employer groups and providers. There is a necessity for administrative functions within the health care system. Third party payers and insurance carriers do provide a valuable service. Unfortunately, BUCA now is the majority stake holder in health care. Until this changes, and employers and providers begin to work together, BUCA and the consultants will continue to take advantage of this lack of connectivity and continue the path of absolute disaster.”

Bravo, Michael O’Grady. The easy way to accomplish your goal is to get the employer out of the picture. As EC pointed out the employer really wants to provide healthcare insurance to his employees. However, it is becoming an impossible and over costly task. Let it be between the patient and the physician. Reducing the physicians overhead by 20-30% will give the physician the ability to reduce his price. If he doesn’t he will suffer the consequence of the consumer walking with his feet and pocket book.

It does not have to be complicated. The primary stakeholders are the patients and the physicians. They should be the interface for the medical care transaction. If a hospital is too expensive, he would send his patients to another hospital. If patients had no choice of hospital the government should impose regulations on the hospitals to reduce the price. It can be done. It can also be profitable for everyone except the stakeholders that profit from the 150 billion dollars of administrative waste.

The healthcare insurance companies would once again be converted to a 6% broker and not the unconscionable owner of the healthcare system.

Stanley Feld M.D. FACP, MACE

We have established that physician fees are not the cause of the soaring healthcare costs. We have not looked at how the healthcare insurance industry tortures physicians with its adjudication of their insurance claims. MILT FREUDENHEIM in The Check Is Not In The Mail accurately describes the physician’s pain in receiving reimbursement from the healthcare insurance industry.

Every physician has experienced delays in payments as well as missed payments. Many physicians’ practices do not have the best accounting systems in the world. The practice management systems can easily overlook non-reimbursed claims for months or forever. Many physicians’ practices have outsourced their billing functions because it is too expensive and inefficient to do it in the office. This has lead to more problems and higher costs. The non–payment of claims leads to greater profits for the healthcare insurance company.

Does the fee charged by the physician get added into next year’s insurance premium charged to the employer buying the insurance for the employee? Does the insurance company credit its profits from the float toward the next year’s premium from its delayed payments? My guess is no.

Physicians pay $6,000 to 20,000 per year per physician just to file and administer insurance claims. They lose countless numbers of dollars from non-payment of claims. The lose countless numbers of dollars from miscoding claims. They loss countless numbers of dollars from the healthcare insurance company’s scrubbing of healthcare claims. There are entire subdivisions in healthcare insurance companies that scrub claims. A simple explanation of claim scrubbing is, if the diagnosis on the claim does not support the procedure, the procedure is eliminated from the claim in calculating the reimbursement to the physician even if the claim is justified medically. Many times the EOB (explanation of benefits) meaning is so opaque that one cannot tell what has been scrubbed out of the reimbursement. A physician’s office can call the insurance company and try to get an answer. However, it is difficult, time consuming, costly and often unsuccessful. Many times I believe it is purposeful on the part of the healthcare insurance company. I believe the goal is to delay payment as long as possible.

Another trick used by the insurance company is to say it never received the claim. Typically, the physician’s office waits a few months until it discovers the claim has not been paid. Then the physician’s office contacts the insurance company. The process of resubmitting the claim and getting paid takes at least another 30 to 60 days. This purposeful inefficiency takes place despite electronic billing.

“Few things rankle a doctor more than an insurance company’s saying it cannot find a claim for medical services. Particularly when there is even a signed return receipt to document delivery of the bill.”
“We actually had the little green card to show who signed for the dang thing,” said Elizabeth Wertz, chief executive of the Pediatric Alliance, a large group of Pittsburgh doctors. “We sent it by certified mail. The insurance company said they didn’t have it.”


The insurance industry is playing to the physicians’ weakness to increase the profit from the float.

“The claim was for several thousand dollars, according to Ms. Wertz, who declined to identify the company, a large regional insurer, for fear of making it more difficult to wrangle payments from the insurance company.”
“ It is a problem known to many doctors as they struggle to balance the rising cost of providing patient care with what they see as reluctance by some powerful insurers to pay promptly.”
“Tardiness or refusal to pay what doctors consider legitimate medical claims may add as much as 15 to 20 percent in overhead costs for physicians, forcing them to pursue those claims or pass along the costs to other patients, according to Jack Lewin, a family doctor who is chief executive of the California Medical Association, a professional group of 35,000 physicians.”

I am aware of a practice in California in which the insurance carrier is 1 year behind in payment and owes the practice $400,000.

How can the healthcare system stop this destructive pattern and dysfunctional behavior? If the patient owned his healthcare dollar, and knew the price he was going to be charged was the price the insurance company negotiated with the physician, the patient could pay at the point of service decreasing the physicians overhead by 15 to 20%. The saving could be passed on to the patient in the form of a reduced fee. The fee reduction would happen only in a competitive environment. I believe physicians would agree to this simply to relieve them of all the stress and costs of collections.

The float is between 29 and 44 days depending on the carrier. Athenahealth a claims-processing company, has published a rare warts-and-all look at how well — or not — the nation’s seven biggest health insurers pay their bills. Athenahealth measured many parameters such as days in account receivable, percentage of claims successfully resolved on initial submission, % of patient liability, denial rate and denial transparency to name of few. The Athenahealth results give us an idea of the unconscionable behavior of the healthcare insurance industry. The tactic plays to the weakness of physicians’ practices and take advantage of both the physician and the patient.

Ms. Wertz, the Pediatric Alliance’s chief executive, says some insurers’ telephone call centers limit claims-related issues to 10 per call. “That’s incredibly inefficient,” she said. “We see thousands of patients. Our people have to sit on phone 30 minutes to get a live person.”

Athenahealth’s other measurements included the percentage of claims paid without changes within 90 days. Medicare came in first, at 92 percent. Champus/Tricare was last, at 85.1 percent.

It should be clear that the way around this waste and abuse is with an Ideal Medical Savings Account. It would motivate the patient to shop for a doctor, and to shop for a good insurance company. The insurance companies would compete on price and quality of product. We have seen the same apathy for reform in American automotive companies until the Japanese gave the American consumer a choice. Now they are trying to catch up.

Who would lose? The slow to reform healthcare insurance company who has abused the healthcare system for many years? Do you think it wants to give up the power it has over physicians and patients? The only way to stop it is with appropriate government regulation, giving patients the power to own their healthcare dollar and total price transparency. It is going to require political leadership that can only be stimulated by consumer demand. Consumer demand will result from understanding the dysfunctional elements of the healthcare system.

Stanley Feld M.D.,FACP,MACE

I feel compelled to dwell on Alex Berenson’s article Sending Back the Doctor’s Bill because it is wrong and distracts from the main problems with the healthcare system. In fact, I find it an insult to our intelligence. I want to include some of the demoralizing examples that are widespread among the physician community. I will start by quoting Dr. Uwe Reinhardt.

“The low lying fruit in cost-containment (ie. physician reimbursement) was strip mined by the HMO movement and Medicare over 15 years ago. There is wide-spread disenchantment and lack of job satisfaction among physicians that threatens to split wide open over further aggressive pay cuts. You don’t have to be a Nobel prize winning economist to understand the inevitable brain drain and service problems you’d create.”

If you review my blog entries on how this all started in the 1980’s you will understand how the easiest stakeholder to attack were physicians.
They are disorganized, individualistic, and political when necessary, and very competitive with each other. In fact, most of the competition has been directed toward and against each other in their local communities. When they perceived that their medical organizations did not represent their interests they walked with their feet and dues, weakening major organizations, that potentially could have aborted the mess our healthcare system is in.

It was very easy for the insurance industry to dominate the practice of medicine. They started dominating the access to care and the price of care. It is only a matter of time before the entire healthcare system implodes because of the insurance industry’s arrogance and greed.

Some physicians have just walked away from their medical practice as conditions worsen and the physician shortage increases. Below is the story of a much beloved physician in Summit County Colorado who practiced there for 25 years. He was at one point chief of staff at the hospital and has served on the Frisco Town council.

Throughout the past 25 years, he’s delivered more than 300 babies, handled countless emergencies, practiced family medicine and conducted altitude research. But soon, he will be moving on.

Sid Schwab M.D. a surgeon nearing retirement said...

“I saw Dr. Reinhardt’s letter (in the New York Times), too. What’s depressing — in addition to everything else in the world — is the misconception people seem to have about what doctors (surgeons especially) do. Hey, cut their pay, put ’em on a salary, or (as one recent commentary suggested) hire a bunch of doctor/moms who’ll be glad to fill in the gaps with part-time work, flood the market –problem solved!”

Snafu Suz a cancer survivor said.

“The American health crisis is many-fold (is that a word? anyway…). There is not one answer to the problem. The whole thing needs a serious overhaul. I agree that cutting doctor’s salaries will hardly help and yes, it will demoralize our health professionals which is NOT a good thing. Personally I have a huge beef with insurance companies and think that would be a better place to start. Health care should not be a for-profit business. Doctors need to be paid just like everyone else, but insurance companies don’t need to be running the show. Maybe we should start there? Maybe we should start with campaign reform so that our politicians are not for sale to drug and insurance companies? Maybe we should start with making higher education universal so that doctors and other professionals don’t have to carry such astronomical debt? Maybe individuals shouldn’t be running to their lawyers hot to sue for things that are unproven? (The silicone implant fiasco comes to mind.) As I said, this problem has many aspects and there is a lot of corruption. Doctor’s salaries are not one of them. The guy who wrote that article is smoking crack. (Alex Berenson)

Susan”

I could go on forever but I think you get the point. We are all in search of the truth. We are all in search of the best way to Repair the Healthcare System. Mr. Berenson’s solution is not the way to repair the healthcare system.