I am a simple physician and family man, trying to make a
living and doing the best I can. I
graduated from Texas A&M medical school in 1982, did a three year
fellowship in general surgery in New Orleans until 1985 when I moved to
Colorado Springs. I married soon after
that and have four children. I worked in
a variety of walk-in urgent care/minor emergency clinics for many years and did
physical examinations for life insurance companies. For the past eleven years I have worked as
the Occupational Health & Medical Coordinator for Colorado Springs
Utilities. So I have seen medicine from
many perspectives; as a private physician, a patient/consumer and now a
municipal government employed physician.
Over the years I have endured the rise and fall of the H.M.O. managed
care debacle, saw the boondoggle of Diagnosis Related Groups (DRG’s), observed
the decline and fall of the solo practitioner as they have been gobbled up by
the behemoth medical corporations and now have seen the greatest insult of all,
ObamaScare. I am not a Harvard educated
economist and I don’t have an M.B.A. from Wharton. I am certainly not a politician (we should
all be thankful). But I do believe that
over the years I have seen some things, endured some things and learned some
things about health care which I would like to pass along to you. Of course, this advice is free and may be
worth what you paid for it.
Let me begin with a little story. About a month or so ago, one of my 17 year
old twin daughters told me that she had been feeling poorly for a few
weeks. She was tired and had a sore
throat. I looked at her throat, it
didn’t look too bad but she did have some swollen nodes in her neck. I called to get her an appointment with our
family doctor (no longer in his own little practice, now an employee of one of
the monolithic companies in Colorado Springs).
Being the middle of the week of course they couldn’t see her until the
next week. Well, by Saturday morning she
was still complaining so I took her to a satellite walk-in clinic run by one of
our local hospitals and on our insurance company approved list. They weren’t too busy and we got in fairly
quickly. I paid my $40.00 co-pay and we
were taken back. My daughter was seen by
a nice nurse practitioner who did a quick history and examination and then
ordered a rapid strep test which was negative.
Following that a quick finger-stick mono test confirmed my suspicions
that she did indeed have mono. A
prescription for some prednisone tablets for throat swelling and we were on our
way. We had maybe 15 minutes of
face-to-face time with the nurse, all that was really necessary. No problem.
Well yesterday, May 18 I got a bill from the hospital. The total charge for the visit was, wait for
it…$770.00. After my co-pay of $40.00
was deducted, a $338.00 ‘insurance adjustment’ (read discount, which would
still make the total bill $432.00) and an insurance payment of $177.69, my
balance remaining is only $214.31! Now
of those charges, $146.00 was for the professional fee (nurse
practitioner). This might be reasonable
for a physician exam, but not for a nurse practitioner. That should be maybe around $50.00. There was a $242.00 clinic fee, no doubt to
cover the overhead of the nice new building they are housed in. Please note this is not an emergency room, it
is a walk-in clinic much akin to your family doctor’s office. And when you go to your family doctor you are
charged only a professional fee, which includes all of the overhead. You don’t get charged a separate clinic
fee. My doctor is housed in a nice, new,
big building with radiology and laboratory services, but doesn’t charge a
clinic fee beyond the doctor’s professional fee. But wait, the final charge was for laboratory
services in the amount of $382.00. This
for a rapid throat swab strep test and a finger-stick mono test. I did some research and found that you can
purchase rapid strep tests for $1.82 per test and the mono tests for $4.49 per
test. This is about what I remember from
my private practice days. Each test is
quick, simple to perform and only takes about five minutes. By my calculation this whole visit should
have come to around $75.00. Here then is
a microcosm of the problems we are experiencing with the cost and payment for
health care around the country.
Let us remember in these discussions that what we are all
talking about is cost and payment for health care services. We have the best health care in the world
here in the United States. This debate
is not about health care. It’s about
payment. The problem with our system now
is that the federal government has meddled in the payment system over the past
decades and really screwed things up.
For some reason health care is one of the few, if not the
only service we purchase with no idea of what the actual final cost will be at
the point of sale. Doctors don’t know,
patients don’t know, the providing institution/company really doesn’t know and
the insurance company doesn’t know until the final charge is hammered out weeks
or months after the fact. This is driven
in part by the coding and recoding of diagnoses and procedures so to as to
maximize the charges by the providers.
This thanks to the ICD-9/CPT coding monopoly owned by the American
Medical Association (their primary source of revenue since only about 13% of
practicing U.S. doctors belongs to the association) and promulgated by the Medicare
system. We need to divorce ourselves
from this byzantine rubric and let doctors and institutions charge whatever
they want in a free market where quality and service-level reviews and surveys
are available for all to see. Let
insurance companies and patients choose where they want to spend their health
care dollars to get what they perceive to be the best bang for the buck.
There are myriad different prices for this insurance company
or that insurance company, for cash, for Medicare, for Medicaid; contract
prices and discounts. The providing
institution doesn’t really know the price up front. Frankly, I can’t believe that insurance
companies agree to pay some of these outrageous charges. The complexity of insurance company
deductibles, co-pays, co-insurance and knowing where you and your family are in
that calculation at any given point in time is impossible, particularly at the
time you are receiving service. Doctors
don’t really know the cost of things they are ordering (and thus incurring
costs) on behalf of patients. There is
no menu up front, in advance like say, in restaurants. I recall a conversation in my doctor’s office
about a year ago. I was having my annual
physical exam and the doctor ordered the usual annual lab work. I asked him to make sure that he coded it as
annual wellness lab work which is covered 100% by my insurance; otherwise I
would wind up having to pay about $500.00 out of my pocket. He was shocked and frankly in a state of
disbelief. He really thought I was
joking. When I explained that I and my
co-workers had all experienced the high cost of these lab tests he honestly
related that he had no idea that it was all so expensive. So to try and put it in perspective, imagine
going into Dillard’s (doctor’s office) to buy some jeans. There are no price tags on the jeans and the
store clerk (doctor) has no idea how much they cost. But don’t worry they tell you, just pay a
little bit now (co-pay) and we will bill you in a few weeks if it winds up
costing any more. Well, how much more
you ask. Well, we really don’t know
right now. So a month later you get a
bill from Dillard’s for $250.00 for the balance on the jeans. And oh by the way, it’s too late to return
them. Would you go for that? Of course not. If the prices were right on the jeans for all
to see you would either buy them or look for a cheaper pair or go elsewhere to
look for jeans. Here is a real life
story. About six months ago on a Sunday
afternoon I drove into Jiffy Lube to get an oil change. You drive right up the garage door and they
open your door and tell you to go inside while they drive your car into the
bay. There are no prices posted anywhere
outside, they don’t hand you a menu of prices or tell you what the prices are
(I know, I should have asked. But
shouldn’t the business tell you?).
Anyway, I got inside and the clerk started ringing up my order while
they started working on my car. The oil
and filter change with a tire rotation came to $65.00. I looked out the window at the Tire World
next door and on their sign it read, “Oil/filter change and tire rotation
$18.99.” I instructed the Jiffy Lube
clerk to stop work on my car and informed him that I did not want any
service. They sheepishly gave me the
keys to my car (I have no idea what they had already done to it) and I drove
next door for service. Why shouldn’t
medical care work that way? One final
real life example. In my capacity at
Colorado Springs Utilities I order a lot of MRI scans. If we do them at the major hospital/medical
corporation facilities they run $2000.00 to $2500.00, it takes several days to
get one done and then a couple of days to get the results back. We recently contracted with a small private
company that does the same scans for about $700.00 to $900.00 per scan, they
often get our employees in the same day we call and the reports are done much
quicker. There is also more personal
communication between the radiologists and me, they are much easier to get in
touch with and get questions answered.
The quality is just as good as the hospitals’ and the service is much
better, not to mention the price! Isn’t
this the way it should be for everyone? What
a wacky system where people are consuming very expensive services, many times
on a moment’s notice in difficult and emotionally charged situations and no one
knows the cost of what is being purchased at the time. It is being ordered by a doctor who doesn’t
know, on behalf of a patient who doesn’t know, provided by an institution that
doesn’t know and paid for by an insurance company that doesn’t know. There is no direct accountability. People are spending other people’s money on
behalf of someone else. And its six
months before anyone has any idea of what just happened, then shazam! Look what we just spent! Oh well, whatever the insurance company won’t
pay we’ll just bill to the poor unsuspecting patient.
With health plans paying less and less of the cost lately
coupled with the federal government lowering the pre-tax flexible spending
account family annual allowed contribution from $8000.00 to $2500.00,
individuals are discovering that they are suddenly on the hook for high costs
that they never were in the past. Much
of this happens after they have actually incurred the costs and can’t really do
anything about it. One result of this
will be that people simply stop going to the doctor and getting tests done,
sort of self-selected rationing. And
maybe that’s what the progressives in government want. But the result will be a less healthy
population, less preventative care and ultimately much higher costs down the
road for late intervention.
Another problem is the costs created by liability and malpractice
litigation and the resulting payments and settlements. We need meaningful tort reform and perhaps a
system like Louisiana where all malpractice and medical liability cases go
before a diverse board who rule on the validity and likelihood of success of
the case before going to trial or mediation or settlement (at least they did
back in the 1980’s, not sure about today).
Sort of like a grand jury. You
can still go to trial with an adverse ruling by the board, but the likelihood
of prevailing is very small. Most
don’t. This weeds out frivolous suits
and grandiose settlements. A cap on
payouts based upon reality and common sense would also help, as well as making
the loser pay the other party’s legal fees.
With all of the vacant commercial real estate available why
do medical companies and clinics need to build fancy new facilities, and then
have to pass all of those costs on to patients and insurance companies? Why not use existing buildings which can be
re-finished for far less than new construction?
Get the government less involved, not more involved. They have already screwed things up and
driven up costs enough with Medicare/Medicaid and now ObamaScare. When the government gets involved they just
screw things up, make things too complex, less efficient and effective and
increase costs 10-100 times. Get the
government out of the way and let the private sector solve these problems. The reason we have these challenges in the
health care payment/insurance industry in the first place is because of
government meddling, regulating and dictating.
To paraphrase Ronald Reagan, in our current situation government is not
the solution to the problem, government IS
the problem.
Get rid of the electronic medical records requirement! Virtually every physician I have talked with
despises electronic medical records.
They are a disaster. They are
impossible to use, they don’t fit the model of what doctors do and trying to
find useful information in them is like looking for a needle in a
haystack. Not to mention the privacy
implications and problems. And I just
received a notice from my malpractice insurance carrier informing me of a seminar
they are going to be providing discussing the difficulty of defending
malpractice lawsuits due to electronic medical records. Just say no!
And by the way, never, never, never let the I.R.S. get
anywhere near health care, health insurance, medical records or anything health
or health payment related! Period. After the recent scandalous revelations need
I say more??
Repeal ObamaScare in its entirety immediately and replace it
only with the free market!
Doctors are now talking about and actually are retiring,
retiring early, switching professions and jobs to something out of the health
field. They are advising their children
not to go into medicine. All as a result
of ObamaScare and the mess the federal government has made of the health care
industry. They are leaving in droves and
the projected shortfalls are staggering.
And you can’t make that up with physician assistants and nurse
practitioners. Not that I would want to.
We must begin to look at the opportunity for different ways
of delivering health care, such as Indian Reservations, off-shore, cruise
ships, concierge medicine, private co-ops, etc.
I know you have heard from many highly placed Ph.D. health
care economists with all of their complicated, complex solutions to the
problem; many including much more government involvement. Just take a moment and think that the
solution might actually be less, not more.
It might be simpler, not more complicated. It might be less government, more private
sector; less government control and more personal freedom and responsibility.
Well, thank you for the opportunity to bend your ear a
little bit from someone in the trenches on the front lines out here in fly-over
country. I hope maybe one little thing I
have said might make some sense and spur some further thought and
discussion. Hopefully we can fix this
thing before we have to wake up Ralph, because of course he ain’t never seen a
wreck like this before in his life (story for another time!). And I fear the health care industry is headed
for a wreck of epic proportions if we don’t do something in a big way and
quick.
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