Comments on: Value, money and time http://www.medrants.com/archives/4053 Contemplating medicine and the health care system Wed, 17 Mar 2010 23:16:37 +0000 http://wordpress.org/?v=2.9.2 hourly 1 By: bushido http://www.medrants.com/archives/4053/comment-page-1#comment-523788 bushido Wed, 28 Jan 2009 20:14:41 +0000 http://www.medrants.com/?p=4053#comment-523788 Extra time can allow higher quality care I don't think many people will argue that. But if we paid for time, Wouldn't that allow physicians to take advantage of being paid for time but not really doing anything helpful? Like a doctor saying he spent all morning with a patient, and all they did was gossip, or the doctor lied ans saw the patient for 30 min and took a very long lunch break? Extra time can allow higher quality care I don’t think many people will argue that. But if we paid for time, Wouldn’t that allow physicians to take advantage of being paid for time but not really doing anything helpful? Like a doctor saying he spent all morning with a patient, and all they did was gossip, or the doctor lied ans saw the patient for 30 min and took a very long lunch break?

]]> By: Martyn Howgill http://www.medrants.com/archives/4053/comment-page-1#comment-523756 Martyn Howgill Tue, 27 Jan 2009 18:19:04 +0000 http://www.medrants.com/?p=4053#comment-523756 I respond first as you request, as a patient, and agree wholeheartedly with your list of recommendations. BlueCross recently decided my primary care physician’s fee-demands were too high (as if!) and terminated their contract with her. She is a thoughtful, prudent and careful doctor who was mindful of the system’s scarce resources. No matter. She’s out. But let me respond now as the executive of a non-profit research organization – www.inhealth.org – that is attempting to understand the economic role and social impact of advanced medical technology through sponsored and independent academic research. It’s our working hypothesis that innovation advances medicine (and vice versa) and that when properly used improves patient outcomes, productivity and the larger economy. Yet increasingly we read that medical technology is the root cause of soaring health costs. Peter Orszag – recently appointed by President Obama to his cabinet as Director of the Office of Management and Budget – published a comprehensive analysis by his former staff at the Congressional Budget Office attributing fully half of the increase in costs to new medical technology. Two years ago, a founder of one of the nation’s largest insurers proclaimed that we could halt health care inflation we just froze innovation! We agree that competing therapies should be better understood, but only within the context of patient and societal values as you recommend. In the face of budgetary pressure, it will be all too easy for “cheapest is best” to hold sway, when more profound, systemic issues – such as the things for which providers are compensated – may well play a more significant but currently ignored role. –Martyn Howgill I respond first as you request, as a patient, and agree wholeheartedly with your list of recommendations. BlueCross recently decided my primary care physician’s fee-demands were too high (as if!) and terminated their contract with her. She is a thoughtful, prudent and careful doctor who was mindful of the system’s scarce resources. No matter. She’s out.

But let me respond now as the executive of a non-profit research organization – http://www.inhealth.org – that is attempting to understand the economic role and social impact of advanced medical technology through sponsored and independent academic research. It’s our working hypothesis that innovation advances medicine (and vice versa) and that when properly used improves patient outcomes, productivity and the larger economy.

Yet increasingly we read that medical technology is the root cause of soaring health costs. Peter Orszag – recently appointed by President Obama to his cabinet as Director of the Office of Management and Budget – published a comprehensive analysis by his former staff at the Congressional Budget Office attributing fully half of the increase in costs to new medical technology.

Two years ago, a founder of one of the nation’s largest insurers proclaimed that we could halt health care inflation we just froze innovation!

We agree that competing therapies should be better understood, but only within the context of patient and societal values as you recommend. In the face of budgetary pressure, it will be all too easy for “cheapest is best” to hold sway, when more profound, systemic issues – such as the things for which providers are compensated – may well play a more significant but currently ignored role. –Martyn Howgill

]]> By: country solo doctor http://www.medrants.com/archives/4053/comment-page-1#comment-523742 country solo doctor Tue, 27 Jan 2009 02:42:28 +0000 http://www.medrants.com/?p=4053#comment-523742 I always wonder how can the insurance companies decide payment on a few codes and numbers? I am known to spend extra time with my patients. Most of my younger patients do not want to be in the office longer than 10-15 minutes for established visits. In contrast, most older patients like 20+ minute visits. I find that I get initial bill rejections for some of the 99214 visits, until I send in copies of my office notes. I think most insurance companies are interested in keeping the payments low from the insurance standpoint, while outpatient copayments keep increasing. To meet overhead, each physician has to see a certain number of patients. Once the overhead is met, then the physician can decided on the personal compensation. It may take me 30 minutes to do a thorough H&P and then go over old records, labs, and studies, but good luck trying to code above a 99214. If I just saw the patient a week ago, I may only be able to get covered a 99212 or 99213, even though time based coding is allowed. The insurance companies routinely reject codes, if there are done too frequently, even though I spend extra time with the patients. During my first few years in practice, most IM/FPs in the area would ask me how many patients I would see daily? My reply is that I see a reasonable number of patients. My income is above the national avg for FPs. To the hospitals and other employers of primary care doctors in the area, a good primary care doctor is one who sees 40 or more patients each office day for maximum revenue to the employer. One local FP doctor is known to see over 50 patients daily. High revenue does not necessarily equate with quality of care, and his former patients often tell me that he never laid a stethoscope on them. On the flip side, most insurance companies are starting to track quality measures, with payments tentatively adjusted to pay better producing doctors who meet quality standards. This will encourage physicians to discharge noncompliant patients. This year I was dinged on some cancer screening tests that my patients failed to do, secondary to multi thousand dollar deductibles. The point of all this is that our current medical system is tied to becoming efficient physicians and doing more paperwork/tracking of quality while limiting reimbursement for the time spent caring for patients. The only current way to maintain salaries in a fixed reimbursement system is to see more patients, which equates to less time spent directly caring for patients. Add in the hours spent dealing with preauthorizations, mail order medications, handicap placard applications, patient phone calls, and other unpaid time, and you have a system that is in a downward spiral for quality of care. The current system suggests that physicians cannot exist without insurance companies, as patients are afraid to pay more than the copay to see a physician. Thousands in premiums are paid to insurance companies, and insurance companies spread fear that patients won’t be seen without insurance. The dozens of insurance companies simply duplicate the same services for almost the same price. The simple solution to the current inefficient system is to switch to a flat fee national system, with adjustments for geographic location and to eliminate insurance companies. I always wonder how can the insurance companies decide payment on a few codes and numbers? I am known to spend extra time with my patients. Most of my younger patients do not want to be in the office longer than 10-15 minutes for established visits. In contrast, most older patients like 20+ minute visits. I find that I get initial bill rejections for some of the 99214 visits, until I send in copies of my office notes. I think most insurance companies are interested in keeping the payments low from the insurance standpoint, while outpatient copayments keep increasing. To meet overhead, each physician has to see a certain number of patients. Once the overhead is met, then the physician can decided on the personal compensation.
It may take me 30 minutes to do a thorough H&P and then go over old records, labs, and studies, but good luck trying to code above a 99214. If I just saw the patient a week ago, I may only be able to get covered a 99212 or 99213, even though time based coding is allowed. The insurance companies routinely reject codes, if there are done too frequently, even though I spend extra time with the patients.
During my first few years in practice, most IM/FPs in the area would ask me how many patients I would see daily? My reply is that I see a reasonable number of patients. My income is above the national avg for FPs. To the hospitals and other employers of primary care doctors in the area, a good primary care doctor is one who sees 40 or more patients each office day for maximum revenue to the employer. One local FP doctor is known to see over 50 patients daily. High revenue does not necessarily equate with quality of care, and his former patients often tell me that he never laid a stethoscope on them.
On the flip side, most insurance companies are starting to track quality measures, with payments tentatively adjusted to pay better producing doctors who meet quality standards. This will encourage physicians to discharge noncompliant patients. This year I was dinged on some cancer screening tests that my patients failed to do, secondary to multi thousand dollar deductibles.
The point of all this is that our current medical system is tied to becoming efficient physicians and doing more paperwork/tracking of quality while limiting reimbursement for the time spent caring for patients. The only current way to maintain salaries in a fixed reimbursement system is to see more patients, which equates to less time spent directly caring for patients. Add in the hours spent dealing with preauthorizations, mail order medications, handicap placard applications, patient phone calls, and other unpaid time, and you have a system that is in a downward spiral for quality of care.
The current system suggests that physicians cannot exist without insurance companies, as patients are afraid to pay more than the copay to see a physician. Thousands in premiums are paid to insurance companies, and insurance companies spread fear that patients won’t be seen without insurance. The dozens of insurance companies simply duplicate the same services for almost the same price. The simple solution to the current inefficient system is to switch to a flat fee national system, with adjustments for geographic location and to eliminate insurance companies.

]]> By: The Jobbing Doctor http://www.medrants.com/archives/4053/comment-page-1#comment-523731 The Jobbing Doctor Mon, 26 Jan 2009 18:51:23 +0000 http://www.medrants.com/?p=4053#comment-523731 Even from the perspective of a different healthcare system (UK, not USA) I have to say that what you write rings very true here. We are fortunate to have a better and more robust system of primary health care over here, although our Government and Media seem hell-bent on destroying it and following the (I believe flawed) American model. We must return to values. Money is destroying our system. Jobbing Doctor. Even from the perspective of a different healthcare system (UK, not USA) I have to say that what you write rings very true here.

We are fortunate to have a better and more robust system of primary health care over here, although our Government and Media seem hell-bent on destroying it and following the (I believe flawed) American model.

We must return to values. Money is destroying our system.

Jobbing Doctor.

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