I would love a cash only practice. Too many patients expect you to bill their insurance as part of your regular service! They don't understand that usually that is done as a favor to them. The patient needs to be involved again in the day to day business end. Unfortunately, I'll never see a cash practice, I'm an ED doc, thanks to the Feds, I have to see and treat everyone without asking if they can pay. :(
As a solo practitioner, I'm already mostly cash. About 40% of my practice is Medicare with limited PPO and no HMO, work comp, Medicaid, etc.
If the government continues to make me jump through more and more hoops or place more unfunded mandates and demands on me, I will just say "To hell with it" and either stop seeing Medicare altogether and concentrate on cash only or retire outright.
On CNN this morning, the House Rep from Minn., in his argument, only used the 63% physician support for the public health plan. That upset me but there was nothing I could do to counter his argument.
For routine cares, it would be cheaper for the patients and lot less hassle for physicians. Families pay upwards of $1K a month for the medical insurance, do they really get that much medical service out of it? No, everyone's buying insurance because they are worried of a catastrophic event that may bankrupt them, and this is where the government should focus their attention at to reduce this fear and help cover this rare but unfortunate events. Patients often complain that we don't spend enough time with them and that "doctors don't really care about me." Well, I have this radical proposal, pay me by the minute and 'll spend all the time you need with me. This would not only bring up patient satisfaction but also create responsibility on patients part, where they will now have a check list of things they want to talk about, not bring 10 other kids in the room while you try to explain something, turn their cell phone off and perhaps even show up on time to their appointments, etc. What do you think?
"Health" insurance adds NO value to the health care picture. Management salaries are outrageous given that they provide nothing of value. My major headache in my office is satisfying the attempts of insurance carriers to deny coverage. This usually involves trying to convince someone with a third grade education, following a check-list, that my diagnosis and treatment is valid. The insurance industry is not spending millions on lobbying for the sake of health.
I'm not sure if healthcare reform would change this too much. The problems with the system that it would raise are already present now (coding, denials, etc), just that there are lots of insurance executives' mansions and yachts being funded by the current system.
A two tiered system will develop, we see this in other countries. People who can afford to pay for whatever care they want will continue to do so. We see this now and will see more of it. For those who are "In the System", they will have to do what they are required to do, they will lose physician choice and probably will see the number of available physicians decline.
Could it move any faster is the real question. I don't see much stopping the trend right now. I don't see anybody where I am opening a insurance based practice and conventional wisdom is that it would be foolish and suicidal to even consider. So that leaves everything tilted in one direction.
Agree with Sermo Doc 3. Multiple answers to question 5 but only took one.
Need to think about going back to paying for office stuff and only using insurance for big ticket items. Need to look at how pharma prices drugs and makes its profit all in the US. Need to stop paying the guys at the top such big salaries. Need to get rid of the rediculous paperwork for insurance.
Had to precertify a brand on birth control pills today because a patient was bleeding on generics. Actually had to fill out the Medwatch form. Pisses me off. And, of course, no reimbursement.
If all you are practicing Medicine for is profit, then by all means oppose health care reform, the public option, and go "cash only". then all you will be faced with is the choice of which wealthy patients you wish to see, You won't be troubled by those nasty, sick poor folk nor their unreasonable demands on your time. You can sit and sip tea and eat crumpets for an hour at a time discussing minor aches and pains with the upper crust.
On the other hand, if you are a physician who engaged in this profession because you felt that you had a higher calling, one that involved caring for those in need regardless of their ability to pay, perhaps you might re-think your opposition to changing the pitiful status quo. The people of the United States deserve access to health care and the current system limits that at almost all levels.
Sure, we need to figure out how to stop wasting resources and make the reformed system work. But waiting for the perfect solution makes no sense. Put something in place, fix the most egregious problems, and let it evolve. In other words, "lead, follow, or get out of the way:.
As a patholgist, I work in an academic hospital based practice which A) will never go cash only and B) doesn't force me to deal with the extra paperwork and hassles of any changes--only the final end result of the department having to deal with decreased revenue. So, I cannot comment on the specifics of the effects on a clinical patient care practice. However, I am extremely against reform, as it stands; though I do agree there needs to be reform of the system. What makes me more angry than anything is the bias in the NEJM study that is being used as reference EVERYWHERE. I know more docs than not (Pathology, Surgery, Oncology, Gynecology, Primary Care) who do not support reform as it stands and have expressed the desire to leave their practices if it passes. I wonder how my day to day interactions show a physician community opposed to reform, and conversations with doctor friends around the country who relate the same sentiment amongst their doctor communities, yet somehow NEJM came up with 63%. I can say that I know 2 out of about 150 of my physician colleagues that support the public option, and they are both not dealing with direct patient care-- pathologists. All of the others are against. That's less than 1% in my personal experience, and I live in the Northeast-- democrat capital of the world. I think that says something. If they really want to know how we think, they should have state medical boards send out surveys to all physicians so each voice can be heard. Polls clearly don't mean a damn thing.
Any of the current proposals will increase the number of physicians with cash only and concierge-type practices. While the current healthcare proposals are all disastrous (I include HR 3200, Obama's "plan," the Baucus plan, and the Republican's proposal for mandated insurance) the move to these types of practices could actually help control costs. They remove (both governmental and HMO's/ insurance company) middlemen from much of the medical economic equation and replace the connection between what the patient wants/seeks/desires and what the patient pays for.
I couldn't answer your quiz because I've never had anything but a cash practice. I take care of patients at less cost and a fraction of the hassles compared to my peers. At this point in time it's only feasible for certain physicians. Several things have to fall in place for it to work, from having the right personality to being in the right place at the right time. I usually describe the necessary prerequisites as the 4 Ps: Personality, Place, Perserverance and Primary Care.
Why are physicians doing the insurance companies scut work as a favor to the patients? Physicians should be paid for performing this service. Just another reason for universal health care.
Dan, I think that if we could move toward a cash system for almost all routine outpatient visits and procedures, which would greatly simplify the transactions, it would be a win for our patients and for us. We would be able to cut down on office overhead, paperwork and the headaches and hassles of dealing with insurance companies.
Insurance should be for those medical catastrophic events that few can afford. Just as we don't bill our homeowners insurance for routine maintainence...we shouldn't use health insurance for this either.
The culture of health care purchasing would change. Patients would begin looking for value and start to understand how to avoid the wasteful practices that we all see daily.
People would realize that it makes little sense to go to the ER for a sore throat or a backache. We may begin to infuse some common sense into an otherwise nonsensical system, where the customer and the provider of service are both blind to the costs.
This is something that I have been talking about since the very first day I witnessed American medicine -- CASH ONLY, period. A very simple, yet very powerful way to reform the US health care system is to outlaw any and all types of health insurance. Then, everyone is COVERED -- i.e. everyone is self-insured. Those who do not have the means to pay, well I am sorry, but, as harsh as this may sound, you have to do something to get those means. After all, if you do not have a roof over you head or food on your table (or the table itself, I might add), no one is going to provide you these things for free -- and these things clearly come way before your cholesterol level check or MRI or Botox (whether for therapeutic or cosmetic purposes). One of the added benefits of this will be that EVERYONE (this includes those who can and those who cannot pay) will behave much more responsibly when it comes to maintaining and improving their health status.
If one can pay cash for his/her food at a grocery store, why they cannot do the same for their healthcare???
Dr. Palestrant, could you please get the "Choose more than one answer" questions to accept more than one answer. I have taken several polls where this feature did not work. Thank you.
The docs in MDVIP concierge practices have it both ways. Their patients pay $1800 a year PLUS their insurance for the privilege of seeing them. If their insurance is Medicare, they have to have a secondary also or they won't be accepted. These guys are doing pretty well.
Wonder whether something similar to the tithe to support the salary of physicians to a respective community would help offset health care costs in a manner that is fair to all.
Cash only is nice but Most Physicians will have to sign up for any government programs and continue with Insurance billing and some direct pay by patient. The Physicians who are Superstar Physicians Researchers/University Hospital may be able to do Cash only. The Physicians who's Specialty is limited to a geographic area where their services are in high demand may also be able to do Cash-only. 90% PLUS of Physicians are going to be stuck with whatever program is passed by Congress no matter how big their talk is of quitting the practice of medicine or their Bold claims they will only take cash or retire. They are Stuck with whatever Passes Congress.
The problem is that most of my practice as a surgeon consists of people who have no choice BUT to attend to their health care needs. We'll never realistically be able to switch to a cash-only practice as the elderly who make up a good portion of our population simply have no income to pay their medical bills.
HOWEVER. . . there is room for reform. Sermo Doc 12, you miss the boat if you think that practicing medicine for the sake of altruism vs. as a way of making a living are mutually exclusive, and I'd be willing to bet that as a pulmonologist, you collect a sweeter salary than mine as a small town general surgeon. Few of us have the luxury of practicing medicine out of the goodness of our own hearts. If there weren't people who understood business in medicine, we wouldn't have any medical practices in our country as we wouldn't be able to afford having any of them!
What we need is to curb the waste in our practices which is, to the overwhelming majority, due to LAWSUITAPHOBIA and GOVERNMENTOMEGALY. You can't jettison the obnoxious patient, tell the family of grandma beth who's suffering from the last stages of dementia or stroke that she doesn't need to have her colon cancer excised, avoid taking the vented patient with metastatic cancer to the OR because they're going to die and their family isn't psychologically prepared for it, or deny care to the IV drug user with their 4th round of necrotizing fasciitis without fear of getting sued. It's become cheaper to throw out EVERY piece of equipment (from drapes to instruments) as it's more expensive to reprocess them due to fears of a suit. LOOK at a patient or their family wrong, and you'll get dragged into court. Your paperwork takes twice as long to complete because you have to document every comment, every pimple and every thought lest you get sued, or - even better - you may not get paid by medicare (which is the standard that all insurance companies have sunk to). Even your H&P has to be twice as long as it needs to be because of these same considerations. Do I really care when my IV drug addict had their last colonoscopy???
In short, we need TORT REFORM, and greater accountability to and by the patients for their care. I would LOVE a cash-only system, as my most responsible and frugal patients are the ones who bear at least a good chunk of the financial burden themselves. We need a GOVERNMENTOPLASTY to reduce the pannus of paperwork hanging over our heads that takes time away from patient care, and has the government determining the lowest common denominator for all care and payment - Obamacare would do just the opposite. Let me accept cash payments at a reduced rate without getting fined by Medicare for doing so! Let us get tax credits on the myriad of free care we provide to the indigent! Give tax credits to those with good insurance instead of taxing "cadillac plans"!!! Yikers. We need PATIENT RESPONSIBILITY for their financial expenditures with limits on care (yes, LIMITS) or increased financial responsibilities (yes, FINES in the form of non-waiving of copays) on preventable items such as obesity, smoking and drug use. We need to set some LIMITS the end-of-life care we provide to terminally ill patients - not through "death panels", but through a transfer of financial responsibility to the family/patient beyond some level of care. We need COPAYS for patients who visit the ER, especially if they're on Medicaid or self-pay to prevent abuse of our overly taxed ER's. Finally, we need some redefinition of the payment-to-risk ratio. If you don't pay me anything, you don't get to sue me unless there's GROSS (and I mean gross) negligence.
Spare us the "fix it or get out of the way" rhetoric. There are plenty of people suggesting what I've suggested (look up the Ryan amendment from 3 weeks ago), but nobody in the government is listening - especially the ones in power, who are more concerned about getting themselves "known" and re-elected than fixing our indulgent, entitled nation.
agree with Sermo Doc 18 whole- heartedly. Get the healthcare industry out of outpatient care. Obviously low income and dependent patients need some type of government assistance just like they get help with food stamps and subsidized lunch programs. But health insurance should be in place only for catastrophic care since payment at the level of small doctors offices is impossible to regulate fairly. Those insurance cards that are basically preloaded with health spending account money appear to be an excellent option for patients as well as doctors. These cards work like credit cards using pretax health benefit money. Pts can shop for the best and most efficient care and the doctors office is paid immediately without the need to reserach benefits, get referrals and authorizations and other nonsense.
Sermo Doc 12 - I too view medicine as a higher calling and thus feel compelled to advocate for a cash-only practice model. As an anesthesiologist my options are severely limited but, even so, I can understand that removing the majority of the 40% administrative cost of medical care from the system will allow physicians to spend more time with patients, offer a higher quality of medicine rather than a higher quantity of tests, and develop real relationships with pts that don't start with insurer pre-approval and end with the insurer's check.
If patients were required to think about their health care rather than simply run for treatment for every ache or pain, then they would also begin to think about how to avoid illness in the first place. If patients had to pay first dollar coverage rather than relying on the insurance companies to cover everything, then they would also begin to balance the necessity of treatment today vs the advisability of waiting a few days which, as we all know, cures many ailments, and they would be able to give due consideration to the costs of preventive care vs the costs of none. If patients knew they needed to pay their physician up front, they would develop savings strategies to cover such an event rather than relying on "somebody else" (or no one) to pay when the time comes. If patients had to purchase their own insurance then insurance companies would begin to compete for covered lives on the basis of clarity and efficiency rather than on their ability to peddle favors to large employers while screwing small ones. If patients had to apply for reimbursement to the insurers whose premiums they paid, insurers would begin to streamline their reimbursement procedures to avoid losing customers, instead of delaying and denying for extra profit as they do today. If patients knew they had to pay up front, they would take the time and effort to shop for inexpensive, efficient care instead of shopping for amenities as they do today. If providers knew patients had the means and the incentive to shop for care, they would find it necessary to reduce prices in order to compete for customers. If patients paid cash for their care they would receive a more in depth interaction with their physician and a higher quality of care, allowing less frequent visits with a better outcome and less overall expense.
Several things need to happen to make a cash system work. Providers must be required to post prices. Insurers must be required to accept all applicants. Patients must be required to carry insurance. Tax incentives must be moved from employers to individuals. Ideally, insurers should compete on a nationwide basis. A safety net for the poor must be reconfigured, and a punishment/incentive system must be established for those who refuse to obtain insurance. All these things are doable, and many/most are already proposed in existing pending legislation.
Medicine is indeed a higher calling, and you should be ashamed for advocating for a system which is certain to serve patients poorly in a mass production environment. People are more complex and more fragile than steel or plastic, and the reason medicine _is_ a higher calling is because of the realization that they need special handling and sensitive interactions. Assembly line medicine, whether run by corporations today or government tomorrow, offers none of the "care" which defines medicine as the higher calling it is; it offers only rushed, one-size fits all service at the cheapest commodity price. If you want it, I sincerely hope you can have it - but it won't be provided by me.
I give a 15% discount for full payment on date of service. Most self pay take advantage of it. If insurance/HMO/etc. sends a form requiring further questions/answers, I will often bring the patient in to ask those questions. This makes sure that the answers are accurate, and bills the aforementioned "care management" entity.
Sermo Doc 12 - Does feeling a higher calling mean I should be trampled upon by insurance/management organizations, government and, yes, even patients?
I just opted OUT of Medicare - it was much easier than I expected. Now I can see Medicare patients, who I love, for cash, and not have to worry about being charged with a felony for a typographical error. Visit www.aaps.org and see how easy it is to do.
I recently told US Senator Michael Bennett that just because the AMA supports socialized medicine doesn't mean that doctors in general do. He can pass a plan, but if 40-80% of the practicing doctors go on strike, it won't do a damn bit of good.
Things to consider:
1. Medicine is a business like any other. Much of our time is spent in the healing mode, but if you don't bring in enough dollars in any given month, you close up shop just like any other enterprise.
2. Politicians don't understand point 1. They also don't understand that simply providing health insurance, doesn't mean that you'll get medical care. Our local US Representative thought that all docs took all insurance all the time. He doesn't have clue that docs can/will pick and choose what insurance to accept.
3. Based on my observations and reading of the bills put forth by Congress, any major changes in our current system (which needs changes, like getting the heavy hand of the Feds out) will result in a two tiered system for Americans. Most Americans aren't ready for this massive change. I predict that their dissatisfaction will be most evident in the 2010 elections. I can hardly wait...
4. Changes made by the Feds WILL reduce reimbursements across the board (just read what the the Congressional bills state!).
5. You will see more cash only practices when the dust settles on the whole system (after Congress is done tinkering). Hey, if you're going to make less money anyway, you might as well go for cash only and save on the paperwork headaches....
6. Why would we want more gov'met involvement when they can't run what they have now (Medicare and Medicaid are financially insovlent). We have knuckleheads running things in Washington DC.
Excellent, Sermo Doc 28! The waste, fraud and abuse is most prevalent at the source of these gigantic bureaucracies. But, they are developing plans to blame us for even more "inaccurate" coding. What will they do if we just don't play the game?
It is not up tp the govt or the patient to take the third party out of healthcare. It is up to the physician.
Just say No and drop participation.
Educate your patients. Reduce your fees to a fair level based on your community. Show your patients how to get reimbursed.
I went cash + traditional medicare in January 2008.
Unless forced to go back to insurance, I will never ever go back.
And for the docs who say that cash only is only for the rich patients, that is untrue.
patients who value your services, and trust that you are looking out for them, willpay, as long as your fees are fair. Much easier to do in primary care than specialties, but it goes a long way in terms of building trust.
The second year of my transition, I switched to a prepaid yearly fee, with no copays, and with an option for auto-monthly-bank drafts for people on budgets.
My patients on this type of plan range from business owners, self-employed, to teachers, Walmart workers, and unemployed.
My fees are fair and I spend extra time and build trust.
So there is no reason why you can't collect a fair fee from patients directly without being called names from other docs.
Physicians have been taken for granted by the insurance companies, and that feeling has trickled down to the patients. Currently, many medical practices are having a hard time making ends meet, as reimbursements are reduced, and overhead only increases. Patients are concerned about seeing their insurance premiums rise, and have no concern for physician reimbursements. Imagine a world where all physicians would switch to cash-only basis, and where they would reduce (or even waive) fees for their less fortunate patients. Insurance companies would no longer dictate fees, and patients would expect their insurance companies to increase the reimbursements (which would now be to the patient - not the physician). No more having your billing staff on hold with Blue Cross for an hour, only to be told "We never received the claim" which your staff knows was sent multiple times. The more physicians opt for cash-only, the less grip the insurance companies will have on healthcare.
Out patient = cash only. Hospitalization- let them take care of themselves - catastrophic insurance bundled packages. Cash only offers better service, better time turnarounds, more efficiency. Probably can go to ten or fifteen minute charge intervals with reasonable outcome, showing patient a large clicking tock in the room will help keep them on time, and a no billing policy known up front. It's time to say screw the government and insurance companies and let them and the patient figure out how much paper work they want to negotiate, we , the physicians don't need to be doing their work. Think of the overhead decrease.
I am trying to transition to cash based in the midwest -- and it IS HARD - my partner, family, management company -- all are telling me I am out o fmy mind and we can't afford to do it -- I keep telling everyone that we can't afford NOT TO DO IT.
I opened up a bunch of mail today with some EOBs and I just cringe (not the least of which is from denials) but from those that were paid: sometimes 45% of what my fee is!!!;
Dropped a bunch of HMOs but still taking Medicare, and the 4 big ones in this area (tricare, anthem, UC, Cigna) and they all suck but I cant seem to get patients in the door - have lost a lot of patients that I have taken care of for many years;
The dentists, for the most part, are cash practices. They'll file a claim for you, but expect to be paid in full up front or will set up a payment plan.
Why is oral and dental health any different than overall health care? If they were able to do it and have that model accepted by most patients, then we certainly should be able to do so as physicians.
I'm and ED physician so I my answers are really only wishful thinking. I get frustrated with the amount of bogus complaints that come in all hours of the day and night from my medicaid patients. I've actually had a few show up and sign in with a bogus complaint just so they can use the phone in the exam room. No wonder health care costs so much. If patients had to at least pay a co-pay to be evaluated, they might think twice about rushing to the ED at 3 am with a mosquito bite. I had one of those last night on my shift.) My insurance requires a $75 co-pay if I'm not admitted after an ED visit. Medicaid patients get free access no matter how ridiculous their visit. Let's make patients be responsible for some decision making instead of giving them a free ride. Lots of hardworking americans don't get the health care they need because they can't afford it while others get everything paid for and do nothing to contribute back to society.
You questionaire was terribly constructed! You really did not appear interested in asking the actual question. No where did one get the opportunity to give their opinion as to whether they thought cash only practices would grow. It assumed that one was actually interested.
So here is my answer to the question. I assume that there are many docs who would prefer cash only, but we have very few who can make a go of one because people are cost sensitive and don't want to pay out of pocket if the might only get partial reimbursement or have a hassle for reimbursement or whatever. It is useful to remind folks that one of the major sales points from the health plans during their biggest growth period was "no claims forms." If everyone has to have coverage the people who now do pay cash will no longer have to. I believe there will be less of a pool of peop[le willing to pay cash or front the cash. I really think there will be a very small number of docs who could maintain a practice of up front payers. Does one really think that a lage population of patients would agree to paying more, or even fronting the money and filling out claim forms if there was another option?
The CASH medicine is here now and can be integrated with existing insurance practice. This year a pilot in Seattle was so succesfull that it is going national this November. I joined PRICEDOC.COM because I can offer discounted services to the underinsured and deductible patients for discount in exchange for CASH and continue with my ever contracting insurance practice. Check it out at www.PriceDoc.com
UNIQUELY AMERICAN
UNIVERSAL HEALTH CARE WITH NO NEW TAXES
Healthcare decisions should be made at the bedside, not in the boardroom.
Let insurance administrators count the beans, but not consume them. They bring no value and neither know nor care about patient care. Corporate profits siphon the funds needed for the uninsured. More than $700 Billion (30-50%) is wasted every year on inefficient administration.
A better, uniquely American system is simple, practical (already proven and in use), and reduces overhead $Billions while it also provides universal coverage at no increased cost. Capitate the whole system under one budget and to prevent overruns, employ an actuarially designed automated daily adjustment in rates of payment for all medical services, drugs and equipment. Excesses by any party-trending over budget will impact all providers who will spontaneously and vigorously monitor and remedy from within Medicine. Congress should exempt anti-trust impositions to promote collaboration and efficiency.
Organized Medicine (AMA, CNA, Specialty Groups, AHA, PHARMA, etc) should collaborate and negotiate for efficiency and quality. Committees already widely established within organized medicine can provide peer review of claims to monitor accuracy, integrity, utilization and quality. Electronic data base monitoring will provide random and selected—focused oversight. Data management and Payment should be digitized and distributed electronically
Please see www.GoodMedicineAmerica.com for more information. Or call
Carter V. Multz, MD, FACP with insights from 46 years of practice and managed care administration.
American Medicine MisManaged Care.
How we can Improve Quality, Add Pharmacy and have $Billions left over.
By Carter V. Multz, MD FACP, FACR (Amazon.com)
My partner and I already have a cash practice urgent care. Most people love it. Makes no difference to those many without insurance and others like the more personal service. I like it because I know the patients who come to me want to come to me. It's not just that "Your on my insurance." We are not rich but we are happy. We offer medicare and medical(medicaid) a discount of 20%.
I have never had a contract with an insurance company. I am "enrolled but NonPar in Medicare. Patients, with rare exception, pay at the time of service. My fees are substantially higher than the community average. My collection rate for office services (as opposed to hospital consults), exceeds 98%. In spite of my high fees, my patients do not spend very much on health care; MI's, CVA's, other serious infections are rare in my practice. While my patients suffer prostate and breast cancers, they do not lose breasts or die from prostate cancer. Higher than average fees allow me to keep my schedule open for patients that are sick or worried. Scheduling 90 minutes for a new patient or 60 minutes for an annual checkup allows for unhurried assessment, communication with referring doctors and appropriate follow up. I have been practicing in this way in a heavily managed care environment for 25 years and I love it.!
I think cash only is the way to go but certainly am concerned about viability. As a subspecialist who performs many procedures not sure how many patients could really afford it but am willing to make it a go if I have to.
I have been a cash only practice for the past 13 years. No insurance, no Medicare, no Medicaid, no drawn out payment plans. Payment at time of service. I charge more than the other guys in town who are insurance/Medicare based but spend much more time with the patient and have a large group of satisfied patients. I make 3 times what I did when I was insurance/Medicare based and I love my practice and enjoy every day. My patients have a choice and they choose to pay for the kind of care that they want.
I practice in NYC, where the disconnect between the cost of doing business and the low insurance reimbursements make earning a living and practicing good medicine impossible. Thus I have gone to an all cash business; that brings up the problem of surgery.
Medicare pays $550 for a scope, $800 for a lami and $1100 for a total joint; my malpractice is $150K/yr. I took a look at these numbers and decided that I didn't want to do 5 cases per week, just to cover my overhead; so I quit doing surgery; a decision made by 5 colleagues I know who are also in their early 60's. The only people operating now are the young guys who can do 10 -15 ops per week (with soft indications) and the academic guys who are subsidized by their hospitals.
Despite training 20% of the nations residents, NYS has an Orthopaedist shortage. 6 counties have no Orthopaedist, 7 only one and 13 only two. Thus 1/3 of NYS counties don't have enough Orthopaedic surgeons to legally run a trauma service.
Patient care is definitely impacted; I expect the whole system to collapse shortly.
Sermo Doc 12 I do fee for service. I quit medicaid when they claimed I owed them money. I actually made more money treating my medicaid patients for free. with fee for service you can do pro bono, sliding scale , and treat every one you see with the same standard of care. I think that is far better than having A MULTI TIERED SYSTEM, DON'T YOU? oF COURSE, i AM TALKING THEORETICAL, AS i ASSUME, SO WERE YOU, BUT i DO DO PRO BONO AND SLIDING SCALE. sOrry for the cps, lock was on. Don't be so quick to judge us fee for service types. It was a way to opt out of a crazy systelm fotr me and to provide the best care I could. I live a middle, middle class life style which enables me to work for a lower income thAN MANY OF YOU SALALRIED DOCS WHO ALSO GET A RETIREMENT INCOME.
Medicine is for profit. If a see a same day new sick patient and do procedures like drain and inject shoulders or knees for severe OA, then I will like to be compensated for this. If you do global fee HMO medicine you will probably give naproxen and good luck seen a Orthopod same day. If you are practice owner this is something very familiar. If you are are an employee it may not. I read New England Journal on the end of fee for service medicine? This people do not practice medicine in the trenches. I guess they do not care about Tort Reform either. In the trenches now for seven years you learn to do GOOD MEDICINE AND GOOD BUSINESS. Plain and simple.
My practice has been cash only for five years. We've opted out of medicare and don't deal directly with any insurance companies. We don't give codes to patients, only receipts. They find professional billers who, working for them for a small fee will use our notes to bill insurance companies. We only have receptionists, nurses and docs. NO billers, coders (very low overhead), and NO interaction with insurance companies nor the government. I spend two hours with new patients and help them improve their health through changing their lifestyle. We often help our patient reduce their weight, cholesterol, blood pressure and blood sugar WITHOUT meds. Many of them could see their other doctors for a small copay but choose to come to us because they feel our services are worth it to them. We reduce fees when we can for patients who can't afford our fees. This is the only medicine that makes sense! It is really reform because it ultimately lowers healthcare costs (as opposed to the high tech and expensive, pharmaceutical, procedure oriented medicine). If the government needs to be involved, let them contribute to low income patient's medical savings plans. That way everyone knows directly what they spend and can participate in making sound medical decisions.
Just CLOSED my practice after losing money with insurance reimbursements to the point of insolvency. Will reopen as a retainer-based practice.
For me- PROS: No more insurance paperwork, less staff requirement, more time with patients, limited practice size, finally making a profit after 15 years. CONS: Having to "market" the concept to patients (initial front-end investment).
For patients- PROS: No insurance hassles, denials, delays. More time with physician, better service, less wait time, NO copays, NO office fees, perhaps choosing a more cost-conscious approach to purchasing health insurance for meds, hospital/ER and perhaps specialists. CONS: Up front cost (usually less than their deductible would be under current insurance).
Encouraging med students and residents to think this route will increase the interest in primary care, as they will be able to see financial gains with their first year in practice, perhaps above some specialists. More primary care PHYSICIANS (not simply "providers") with smaller practices will allow better primary care, decrease useless referrals (freeing up specialists to devote time appropriately to cases requiring their expertise), decrease hospitalizations, and perhaps force the industry to take a look at the disproportionate cost of MANAGING health care rather than PROVIDING health care.
i have watched goverment programs routinely for YEARS CLAIM WE, the DOCS are the source of the high cost of MEDICINE when THEY , ie Medicare , KNOWINGLY UNDERCHARGED for 24year and now add an additional 18 to that! THE GOV LIES regularly and points finger at others when THEY ARE CULPABLE.. then they accuse US of FRAUD and not following some Written guidelines which no longer work in certain patients.. so THOSE WHO CAN go CASH NEED TO.. this way you will have fewer DOCS caught up in INSANE PAPER Accusation SWIRL..
I did not take medicaid and hmos. and some of my best Patients were those who PINCHED pennies for quality and actually WORKED with ME to get better!!!!! I stopped Medicaid WHEN the cost and time of rediculous paperwork far exceeded the paultry reimbursement from Medicaid........I discussed in generalities cases with hospital docs.. over the phone.. as to how I would treat My family in certain situations... .. to further educate them.. The hospital docs were very grateful for this! and never took advantage of me.. It was part of their ongoing ed..........SOME specialists will be hard to get away from government mandate to see all in ER etc.. but the rest of US can create sanity for the majority of patients.... I TOLD UNINSURED patients.. that , even if I was cash.. THEY MUST HAVE CATASTROPHIC INSURANCE in case needed hospitalization............. Some of my medicaire patients spent more each week on GOLF than on health care........ at some point , when they value their care , they WILL GO TO CASH.. and not be caught up in "the GENERAL style CLinics.
and the the YOUNG DOCS>> , they must quickly get out of DEBT so they can free themselves of THE INSANE GOVERNMENT AND LEGAL SYSTEM. who have both become equvalent to the EBOLA VIRUS.. I do hope this SICK Infestation can be HEALED with getting them away as they are absolutely INCOMPETENT in even being associated with medicine.
the problem if you become a Salaried Physician will be JOB STABILITY FOR YOU and your family. BEST to increase marketing and patients and referrals for CASH ONLY
Many of the comments here are insightful and thought provoking. A few of my own thoughts: 1) "Cash only" doesn't necessarily need to be only for the rich. For office visits, education, counseling and the like, rates can be comparable or less than other professional services and (if not prevented by regulation) one can have some pro bono work either in the practice or through local foundations/charities. 2) The keys to having the above function is controlling administrative costs (i.e. not dealing with insurance billing). 3) Patients need to know where the money they (or their employers) pay in insurance premiums goes. I believe if this information were readily available, cash practices would grow and a market could develop for plans that cover expensive events (hospitalizations, surgeries etc.) with low administrative costs, modest executive compensation and thus lower premiums. This might or might not require regulation to accomplish. If (hypothetically) a patient, union or business has a choice between a premium of $300/month and $60 for a 15 minute visit vs. $1000 premium and $40-50 "copay" ,many might want the former. The overall expenditures --on a societal level--would be lower and the physician would make more money and have fewer headaches. 4) Something needs to be in place to cover the kind of care almost no one can afford on their own. People with low incomes could receive subsidies to join the market or be cared for in clinics staffed by salaried physicians. Loan forgiveness or scholarship programs could be offered to draw young physicians to work in such clinics. 5) HSAs could be available to encourage preventive care and help people with chronic conditions afford office visits over the year. 6) With lower administrative costs and not needing to cover routine office visits, perhaps compensation for surgeries etc could be adequate.
Out of 1000 doctors who blow hard about cash on the nail only a hand full have the guts to do it. Doctors have tasted the easy money of Insurance but now like Dr Faustus we have the reckoning.
Sermo Doc 45, excellent model for the primary care physicians of this nation to emulate. Patients pay because they receive a valuable service. They are not herded through a system with minimal personal contact to reach a corporate target.
How uplifting! Common sense and intelligence exist in American medicine without ANY government or corporate involvement!
I'm in the process of going no insurance, cash only. I've dropped several, the biggest being Humana which goes down in December. I'll also go non-par with medicare. I'm doing step by step because I don't feel secure enough to do it en-mass but am really encouraged by what all of you have said. One of my patients when finding out about me not taking Humana was furious. I explained why I was not. It didn't help. She then told me she had the money but didn't want to pay me more. Her co-pay is $10! So my value is only $10 to her. I no longer feel bad at all! She has been my patient for about ten years and I have helped her survive several horrific problems. And my value is TEN DOLLARS! I'm headed to cash only. I'm totally burned out chasing my tail all day trying to get so many people taken care of. I also take care of all the business (solo practice). I've started making wine and hope to open a winery next year. I'm pulling my nose off the grind stone!
to Sermo Doc 8-I've been in practice 29 yrs in one of the most heavily insured populations in the country and we've always had a multitiered system!!! (not just 2)...
a tier is always more aptly defined by each patient who brings their own set of values/biases/misjudgments of what they perceive as adequate care...
the uneven unfair care fear of a multitiered system is not germaine nor evident...
what is unfair and uneven in this land of 3+ million of the most heavily insured is the lack of prim care internists to see to have any care at all...
our current health insurance and medicare system of price fixing OUR VALUE below market levels x 25+ yrs has dried up the MD resource permanently!!!....now that's a moral quandry worthy of national debate...
the real question for Americans is not about the uninsured and access BUT that the insured will most certainly be undoctored and have access to nothing!!!
I hope so, as I think it is where most patients should be. Responsible for their self w/ insurance helping with catastrophes. Plus, less headache for physicians....
We as physicians have lost our constitutional right to free enterprise. We cannot balance bill. When the government is the master and we are the slave it is despotism. Despotism is a form of government by a single authority, either an individual (Despot), or tightly knit group, which rules with absolute political power. You don't think so? Try collecting more than you are authorized. Your patients will call the 800 number on their Medicare bill and you will be in jail. If you take cash only ("opt-out") then your patients CANNOT submit your hand written bill to Medicare.
Its high time everyone began to take responsibility for their actions.
If patient's exercised, ate properly and avoided tobacco, and substance abuse the cost for health care coverage would dramaticaly decrease; and those who chose to ignore their personal health responsibilities should be charged a premium for coverage.
If physicians stopped participating with low reimbursing insurers, then we could all start to enjoy the benefits of a market driven health care system and physicians could control the quality of health care delivery.
If the politicians would face the facts and address the real problems, not use this as an oportunity to push a leftist agenda, then we would see tort reform and insurance competition.
The facts are that none of this is likely to happen. Yes, everyone will complain about new regulations and decreasing reimbursement and even threaten "to go cash only", but if that were true, then why continue participating with insurers who have imposed draconian, unfair and sometimes illegal measures to further tighten our cash flow, for years on end. The fact is insurers don't respect us, politicians (lawyers) don't respect us and now we are about to lose what little respect we have left from the only group that realy matters, our patients.
I really hope I am wrong. I hope we finally do stand up for what is right. Our right and duty to exercise the privilege to care for those in need. This is what it is and has always been about. No, we don't need goverment telling us how to practice. We don't need insurers telling us how to practice and we don't need lawyers preying upon our patients like vultures in the Kalahari. I can try to educate my patients to the benefits of investing in their health through exercise, proper diet and tobacco abstinence. I can waste my energy and money trying to influence a corrupt political and legal system that has latched onto our health system as the goose that lays the golden egg. And most importantly I can retain my self respect and my ability to practice as I see fit by saying NO TO PARTICIPATION.
This topic has been discussed in great details. It is very clear to me that COP is the way to go for doctors and for pt. Return healthcare to free market if you want to save this country. There is no such thing as free lunch. If govt offers that, someone is paying for it in some way.
Entitlement burden coming from govt takeover of healthcare will sink US.
As a solo family doctor, I also still admit my own patients. A cash-only practice would disallow this continuity of care. I see few other drawbacks. I'm curious, though: How would we assist the patients in filing their own insurance claims, as I know few people who can negotiate such paperwork without understanding the system?
My own personal family practice physician began his cash only practice about 5 years ago. It works very well. I pay up front, a reasonable price (approx $200 per hour, in the Midwest), and have his undivided attention during the visit. He doesn't have to rush me through, which is comforting (in terms of body language), when performing the physical exam, etc. At the completion of my visit, his secretary hands me an insurance claim form, with the CPT codes already filled in, so that I can submit it to my insurance company for reimbursement. He spends ZERO time dealing with third party payors... that responsibility (appropriately) lies with me, the insured. I hold the "hammer" that he doesn't, when trying to collection on a claim, namely, if they "stiff" me, their insured, I can quit my policy with them. I'm a radiologist.
Sermo Doc 59, very nice! What a concept...patient owns insurance...insurance company is responsible to provide promised service to patient...if not...you fire them!
A truly revolutionary idea...seems to work for almost all other businesses in America.
I am a specialist in a small practice, and we accept a wide range of insurances, including HMO and medicare. It has become almost impossible for me and the staff to keep track of the different insurances and there billing and laboratory requirements. For example, different insurances require pathology specimens to be sent to different labs, which means a different specimen bottle, labeling, specimen requisition, and courier for the different types of insurance. Frequently, although all major procedures are pre-certified (due to a large number of patients giving fake insurance, outdated insurance, and the like) the insurance company will deny the payment based on the results of the pathology, which requires refiling or sending supporting documentation. This is just one part of my practice as a physician, but it is unsustainable. The burden of the insurance is going to have to return to the patient to understand their insurance and seek reimbursement from them. The overhead to deal with the requirements of private insurance and medicare is increasing drastically and payments continue to fall. I don't see how this is sustainable for a small practice or even a large one. I think the cash system will become incredibly wide spread, simply to reduce overhead.
I have had similar experiences to the doctor who said his value to his patient was $10 dollars for the co pay, this is a routine occurrence.
Sermo Doc 59: Even better would be to give NO codes, only receipts. There are professional billers who when paid a nominal fee by your patients, will turn these receipts and your notes into CPT codes and bills. In this way you have ZERO responsibility toward the insurance company. You can't be accused of fraudulent billing (upcoding etc.) because you've never represented to anyone ANY codes. True freedom. Your only relationship is with your patients!
One major problem we are overlooking. If the spending spree continues out of DC, the continued printing of money, with no value backing it, our creditors will call in their markers and paper money will only be worth the paper!!!
Instead of "cash only", we should consider barter only, when the cash has no value.
Like Sermo Doc 59's doc, I have had a cash only urology practice for the past 8 years. I do provide CPT codes on my reciepts, but there is a disclaimer on the bottom that states that I make no effort to accurately code and patients rely on these codes at their own risk. Generally, their insurance companies pay them based upon the codes and I am out of that relationship. Private patient oriented medicine is the only ethical way to practice medicine. After being in the 'system' for 10 years and out for 8 years, there is simply no discussion. All doctors need to get out of the system and work for our patients. The insurance problem is for others to solve. In fact, when patients are dealing with doctors, we will become better at patient care and medical service. When patients deal, as customers, with the insurance companies, they too will become sensitive to the patient or risk losing the business. For doctors to remain in that relationship is similar to one who enables a junkie with one last fix. It's that simple.
I already run a cash only practice. My billing is my credit card machine. The only insurance offers is a pot of cash they can disburse (to hard to get at it and they don't provide any support to access it), and a referral base (thankfully I have a steady referral base). While this is not in the public health interest overall, I do get a comiitted, ready to work patient group who is serious about their care. I have less than "wealthy" folks who come, but they prioritzie their expenses and make it their business to make the treatment happen. Then, I can know my patients, treat them well, see them get better. When they are stable, I will refer them back to the pediatrician or "in plan" doctor which works out fine. If some one can't pay at the outset, I will help refer them to an in plan doc. Those that are chronic patients, in need of long term care, I try to assist them into "entitlements" such as SSI or Medicaid and get them to an approrpiate agency. I know they are spending their own money, so I want to titrate the intensity of care, to the need, I get to spend more time, and then, if there is "extra" work involved to make things better, I don't mind, because I am not resentful that I work for an impersonal insurance company. I think the health insurance industry is a legalized mafia - my saying is - "They can because they can and they will"
I have a small cash-only urgent care Pediatric practice where I do house-call only care. I started this two years ago and have only done word-of-mouth "advertising". I've been successful enough doing this to make my malpractice payment monthly, which is my main source of overhead.
By no means am I busy enough to look at this as my sole income, so I also do locum tenems part-time. But my house-calls practice is what I truely love. And I do find that parents are willing to pay me for my time, and they're grateful to have access to a physician willing to answer their questions. Personally, I find the patient-doctor relationship much more emotionally gratifying doing this, than any other practice venue I've been in.
I'll keep doing this as long as I can keep making my malpractice, and I suspect that when I hit the 5 year mark I'll be able to cut back on the locum tenems.
Government-backed catostrophic care (voucher for those who can't pay, tax credit for those who do), encourage medical savings accounts, and cash pay for outpatient visits and most pharmaceuticals . . . why wouldn't that work?
Oh, that's right, the government and the insurance companies would lose CONTROL . . .
Venting frustrations here is unproductive. Intuitively most know that government intrusion, or politicians to be more exact, are largely responsible for the soaring cost of health care. Politicians would never admit this and will repeat the same process with whatever system they force down your throat while expecting a different result. This is the definition of stupidity. Fee for service sounds like a good idea but the public will have to be educated to accept this which would be an extremely slow process, perhaps taking decades and perhaps never. In the interval I imagine a few physicians capitulating or starving.
I've been cash only for 5 years, and doing very well. Insurance companies don't know what to do with me. I have an urgent and Emergent House-Call Practice. I deliver care in the home, that costs 2 to 3 times what the ER would charge. My patients seem to love it. One of the services I provide is allow patients to truly understand how crooked the Insurance industry is. I also feel that Insurance companies are less inclined to screw the people who pay the premiums. I am willing to do whatever my patients need, within reason to help them get re-imbursed. The games played by Insurance companies are quite imaginative.
To those in favor of more high deductible health plans and health spending accoutns...they add nothing but more work to my day. Each patient with one of these plans nit picks about which labs to order, which medications to take, whether they really need that ultrasound for their scrotal mass, etc. For chronic conditions like asthma and hypertension and hyperlipidemia where I'm being graded on patients' outcomes for quality, the patients have a disincentive to do the labs that I request to evaluate their progress because they don't want to pay for them. It costs them money to do so, it costs me money when they don't do it.
I've been doing a no-insurance cash practice for nearly a year, after having tried an insurance practice for a few years prior. The first few months were a little scary, but now that things are rolling, I will NEVER go back to an insurance practice.
Yesterday, I got an EOB from a patient appointment in December 2008. It was a joke. I can't believe I put up with that kind of crap for those years....low reimbursement, insurance discount, waiting 9 months to get paid. Forget that. I'd rather work at Starbucks than go back to an insurance practice.
No one needs health insurance for office visits. Think of it like car insurance. Who expects their car insurance to cover oil changes and gasoline? It's ludicrous.
Name any other "business" on the planet that is required to provide cutting edge services and technology to whoever walks through the door, regardless of their ability to pay. The name for that is more accuately, an entitlement. Start there. Then get. rid of everyone thats being paid to say "no" to the diagnostics and treatment plans designed by the only people trained to prescribe them. Address as well the money wasted on liability issues and you could pay for those services ten times over. Since physician and nurses salaries havent risen significantly over the years while healthcare costs have soared, cutting the pay to providers will drive them from the business and dramatically limit access.
US healthcare is a mafia, a Ponzi scheme of kickbacks. Imagine how well we could practice by cutting charges by 50% , eliminating all billing staff and running the office with one secretarial staff and possibly a med assistant. The patience of doctors is constantly tested and even we are reaching a tipping point. Our decency is mistaken for naivete and stupidity.. Something needs to change and to put in the C-in-C's own hackneyed phrase, "The moment is now"
I have had a cash practice for over 10 years. People ask me how I do it. Well, I tell the patients how much I charge, ask them to pay me, and they give me a check or credit card, at the time of service. We file insurance as a courtesy. I am a psychiatrist, so it is quite easy, as I charge based on my time and complexity. I also charge for phone calls that are more than brief answers to simple questions. I charge for forms, letters, reports, etc. Can you imagine going to the grocery store, loading up your cart, then at the check-out counter telling the cashier to bill your "food insurance"? Can you imagine asking how much the lettuce costs and being told, "Well, that depends on your insurance and whether we have a preferred rate." Imagine asking how much you owe and being told, "Don't worry - just pay $15 now and we'll send you a bill at the end of the month after we see what we collect from insurance." Isn't food a basic human right? Water? We are expected to pay for those things every month based on our utilization. Why is medical care different? It's different because we, as physicians, went along with this ridiculous system for over 50 years because we were being reimbursed in ridiculous amounts, basically charging whatever we wanted because insurance paid a certain percentage - without asking questions. We need to get back to a system that involves the patient feeling the cost. There is nothing unethical about that. Any third party between the patient and the physician - whether an insurance company or the government - screws things up.
I have a cash-only practice. I used to take care of over 4000 patients and now my practice is much smaller. My life is wonderful. I am actually having family dinners with my children. I can spend lots of time with my patients and am now doing housecalls. I find housecalls to be very rewarding. I used to do housecalls when I first started practicing 20 years ago but had to stop when I became so busy.
The only disadvantage may be the guilt feelings of not being able to accept all patients and not being able to care for everyone. I have solved this solution by now volunteering in a free clinic several days monthly. With my new schedule, I am able to volunteer and teach medical students, activities I had to drop as I became busier in my old practice.
Standard healthcare is a lot more affordable than people realize. Doctors' fees will likely be less if we all accept cash only. No dealing with insurance companies, no trying to justify your notes for a given CPT code, no extra billing overhead... The only insurance people need is major medical. You use your auto insurance for a total car wreck, not for each oil change or scratch on your car, right? You use your home insurance in case of fire or flood, not for minor home issues like a clogged drain, right? Health insurance should be used for major health illness. Major medical insurance cost a lot less and if all doctors moved to a cash practice, cash prices for routine care and procedures will decrease and become more affordable. The cash price for a CT scan is about $400, not $2000 - $4000.
Looks to me like Pelosi wants Medicare for all. Get ready for a sales job on what a great revolution in quality of care and success Medicare has been.
I see for everyone what we have done in our practice the last few years...
Refuse Medicaid (except emergently, family members of long established patients and colleagues).
Become NONPAR on Medicare and collect EM services up front (bill after a deposit for procedures) until the time that the Medicare limiting charge does not cover costs (next year if it is not fixed), then opt out of Medicare at any quarter that it fails (which screws the eneficiary unfortunately).
Leave bad payor contracts. We even left Blue Cross. It wasn't simple or easy but has gotten us exactly what we needed...adequate reimbursement. Moreover, we have had other networks now come to use with much better offers up to 150% of Medicare.
Filing a claim electronically is not a really big deal. This is simple. Most EMRs and practice management systems do it at very low overhead. It is trying to collect balances which raises overhead. Giving a discount for paying at time of service is the key to collecting up front.
So many informed and thoughtful comments!! There is no perfect system--anywhere, for any particular product or service. But, there is one which is the least imperfect, keeps prices low, access easy, meets everyone's needs and many "wants". That's free market capitalism with minimal, if not miniscule, government involvement.
When patients are paying for services they receive the market will respond with cheaper MRI scans, shorter waits in doctor's offices, ?ultrasound booths at the mall?--- hell I can get my teeth whitened there!
The same system brought 1980 $3000 VCRs down to 2009 $29 DVD players,etc...... there are countless examples.
All socialist systems end by collapsing, leaving their dependents destitute. Move to cash now.
Just got back from my PCP where I asked him AGAIN to go to retainer practice (like Sermo Doc 30) so that he doesn't use up all his ATP and become a small pile of dust.
I don't think there's any legal way for the government to stop this transition. The worse they make third-party interactions, the faster it will happen.
Patient education is the key. DON'T call it concierge practice, everyone thinks they can't afford it. DO shout loudly about the $XX / month direct debit from the checking account.
Providing patients with MSAs that were pre-funded by their employers or the feds (for low income) would cut the whining about the costs of labs.
The best 'spending plan' for patient responsibility:
MSA with 2 grand from employer (annual but employee doesn't own), 2 grand from employee (can accumulate, employee owns), then 'overage' or 'catastrophic' insurance kicks in. Lots of competition in the design and pricing of these plans.
Cash based practice may not be the ultimate ideal health system paradigm, but at the moment it allows (especially primary care) docs to practice ethical and sustainable medicine.
At a meeting earlier this week, Erika Bliss MD from Qliance presented data on the cost of dealing with insurance in a typical primary care office. According to the study in Health Affairs, the national cost is $31B/yr, average of about $68,000 per doc per year. The costs increase in primary care. Each claim submission comes with fixed costs. The smaller the claim amount, the greater the percent of the claim eaten up by the fixed costs. In Dr. Bliss' calculation, primary care loses about 40% of payment to the costs of billing. This cost analysis does not account for the extra costs of dealing with prior authorizations and other administrative trivia. Primary care practices that have moved to the direct practice model (aka 'cash practice') have gotten off the hamster wheel, can spend the time they need to deliver on their full professional obligations. I don't mean to say that this delivery is ubiquitous in or exclusive to direct practice, just that I see these practices as finally having finances aligned with the work of being a good and effective physician. Some salaried systems approach this level of simplicity and elegance, but now we have options beyond 'salaried' to achieve professional and ethical alignment with our patient's best interest.
Until there are sensible, rational, and ethical policies that truly support good care for our patients, we can look to direct practice as a setting where the possibility exists to close that gap right now.
The Government will try to eliminate or restrict Cash payments. This is not a "touchy-feely, help everything bill" this is a definate power grab. The writers of the bill want control of the Medical Industry and the patients, they don't want a segment of medical care that is not under their strict control. Read the bill, the proponents who have not read the bill are voting with their heart. The bill is not written in this spirit as far as I can tell with two readings (the first version is the one I have studied).
Sermo Doc 80, you are correct. That is why we must derail these bills and begin again with a constructive national debate that exposes the REAL issues.
If you want everyone to have healthcare, make every health cost tax free. Make everyone pay into the system. You cannot get something for nothing (as so many think will be the case).
I know this isn't the total solution, but our system isn't that broken. Our government run option (Medicaid/care) is poorly managed, and the oppressive restrictions force insurance to work harder for profit. I love Atlas Shrugged, and I really feel like the book becoming reality..........
Why hasn't anyone cornered Obama and said, "please explain to us why health care costs so much?"
for some of us that run a private practice ...we are the only Business in which
a person(the pateint) gets instant credit(Health ins billing) by just walking in without any financial assessment.
It would be fantastic to have a fee for service-cash only practice . The patients
don't seem to understand that billing their insurance co is a service that
we are providing and not a patient "RIGHT". If you are a unique specialty
in demand without much competition in the area you may be able to test the
Cash only practice ,otherwise patients will leave if they have to pay more than their
copay.
Just submit the results of this survey to the White House, senators, politicians, insurance CEOs, and other bureaucrats. That should do it, without much debate.
How many people expect their auto or property insurance companies to pay for routine maintenance? One main problem is that people don't understand the cost they (and employers) pay in premiums for insurance to take care of everything, including routine care. I agree with Sermo Doc 5 in that reform should be focused on changing the concept of "someone else" taking care of the bills and paying for it through taxes and increased premiums. Health insurance for the vast majority needs to be shifted to major/more expensive health events and routine care not even billed to insurance (think of the practice and premium savings!).
Doctors should unite and stop accepting any forms of payment but CASH! Payment should be made at the time services rendered. Thge patients then can submit their claims to whoever!!!!! Thats the only way to regain our independence from insurance companies and the oppressive government.
I'm already "cash-only", and I'm glad. I opted out of Medicare 1 1/2 years ago, and I never took any other kind of insurance. I still see some of my medicare patients, at significantly reduced fees that they pay me out-of-pocket, and it's worth it. If a patient can't afford my full fee, I'll reduce it to something they can afford, and I can afford to accept. If we can't reach an agreement, I'll refer them somewhere else, and I won't charge for the initial consultation. But that rarely happens. Because my husband is also self-employed, we have no reduced rate on insurance, so we have only catastrophic insurance, and we pay for our medical care out-of-pocket. It costs us less than it would to have full coverage, even last year, when my son had knee surgery. And we don't run to see a doctor for every little thing. It's totally workable this way. Couple this system with Health Savings Accounts that let you carry over from year to year, set up efficient clinics for people who really can't afford treatment, and you don't need crazy universal coverage. Using medical insurance to cover every little office visit is like using auto-insurance to pay for gas. It makes no sense.
Something that pushes me more to a cash business is that stupid federal trade commission requirement that businesses that extend credit willingly or otherwise have to comply with insuring credit security of the transactions. THis is the thing that has been put of 3 times now but it certainly adds fuel to the fire. I also agree there will be two tiers in healthcare.. plus tell me what are we going to do with 46,000,000 new patients helthcare is strappeed by what it has now.. again 2 tiered system
I didn't go into medicine to get rich. I have lived in the same house for almost 44 years. My wife's car is a 1991, and mine is older than that. We live modestly. Calculated by the hour, I probably take home less than a plumber or a member of the UAW. The bottom line has been gradually eroding for several years. Overhead goes up and insurance payments go down. And I have been giving more discounts and outrignt charity with the recession. My biggest practice problem, though, is the third party interference that wastes my time and my nurse's time and interferes with my ability to give my patients the best quality care. Medicare is by far the worst, but the private insurance companies are gaining on Medicare rapidly. Medicare fees are less than overhead, and the only way to survive economically is to cost shift. If the Feds take over, and we are paid for all patients on a Medicare fee schedule, then I will be out of business, unless I can opt out and deal directly with my patients the way I did when I started practice in the mid-1960's.
If all the other Derms in my area would go all cash so would I. Otherwise I can't compete practicing general dermatology as cash only because patients need to be "re-educated". My solution has been to move more and more into cosmetic dermatology so that it now makes up 50% of my revenues. If BO gets his way it will have to be 100% . Patients need to be careful what they wish for. Free Healthcare = No doctors or at least no specialists. ( I actually love eating crumpets with rich people Sermo Doc 12. Please send them over)
There is already a blue print for govt health care.That is Public Health Service,Military medicine and VA.Just extend the PHS to general public.No need for filing.Doctors and paramedical personnel are salaried with benefits.Those who wish to have their own practice can still do so.That way public has a choice.Just like public schools vs private schools.It will solve the access problem but the quality of health care will be whole different problem-
Only health care reform will save health care, but not they way most people think. Increasing access will only offer patients more of the same nonsense. Five years ago when I awoke from my 18 year "medical-training-induced-drug-prescribing-stupor" to realized that my profession (except for surgeons) had become nothing more than a marketing arm for the pharmaceutical industry and most of my colleagues still today don't even know it, I sought our doctors who had already figured this out. The first group I found was the American Academy of Anti-aging Medicine. They were overwhelmingly former ER docs who were running cash based practices and were mostly men who had learned what most male doctors still have not, that men lose hormones as they age and thats why they fall apart, grow fat bellies, man boobs, develop insulin resistance, lose their confidence, etc. They were doing HRT in men and women and making quite a good living.
The incentive structure of medicine that offers a premium for procedures encouraged doctors to practice specialty medicine, but it cost them their ability to understand how to do prevention, for themselves or their patients. However, these are the doctors society is listening to about everything, but they can only offer us rescue care. They started telling generalists what to do and how to practice, but they can't see that what they offer is a fragmented perspective that presumes that patients have only what they treat. It took me years to figure out that I could not follow the recommendations of specialists for prevention, only for rescue. They cannot see that my patients have multiple problems that require a comprehensive solution to all of their problems simultaneously, specialists could only offer me "parts" advice. The problem with medicine is the medicine we practice. We can't even see simple solutions to patients problems. Gastroenterologist think that it is ok to continuously suppress peoples stomach acid, for example. They are completely unaware that they cause patients neurological problems when they do, since patients don't return to them with the problem they don't see the problems they cause. It is inconceivable to neurologists that patient's dementia can be caused by problems in their stomach. There is no working model in medicine that even acknowledges people's parts interconnect. Doctors are victims to their own inability to see the big picture and suffer from all of the same diseases as their patients while taking all of the same drugs and having all of the same procedures. Patients just hop from doctor to doctor getting another drug with new side effects. The plan for everyone in insurance (patients and doctors) is to die on 20 drugs. Some doctors have long since figured this out. I have began a grassroots campaign to explain to patients just what they are getting from the insurance market, rescue care and nothing more. I do not rely on my insurance company to keep me healthy because they have not a clue how to do so. All smart patients are willing to pay out of pocket because they know that all conventional medicine has to offer them is more and more drugs, and doctors simply have been brainwashed by training to do nothing else. Its not their fault, but is true that if a non-surgeon doesn't have a drug for a patient, they don't have anything else for them. I do not want to dismantle the rescue care we have, but doctors themselves can expect to get all of what they see in their patients until they realize they have been punk'd by big pharma, they own you.
When has insurance even given us anything but restoration from catastrophes anyway? Car insurance doesn't provide maintenance, neither does homeowners, and we know somebody has to die to collect on life insurance. Why do we think that health insurance offers people anything different? It doesn't its just an illusion. Medicine is priced out of range for most people to access without insurance, so people think that when they use insurance that they are getting prevention. They are not, its just rescue care just like other forms of insurance. Some of us have figured it out, most people still have not. Many doctors who are running cash practices practice fundamentally differently (not just the concierge practices, they are just organizers for a fee). Some of us actually returned to the use of basic science, that most doctors abandoned, in lieu of prescribing drugs, which is why they don't understand the cause of anything.
OK so all this talk of cash only practice has intrigued me. I have a couple of questions for those of you who have succeeded in this realm. 1. How do you deal with referrals? If a patient has BCBS/Aetna etc.and they need an MRI, specialist referral etc. how does that work? If you are not in network you can't. 2. Meds - I am constantly pummeled by the fax from the Ins. Co/Medco about formularies etc. Do you just tell the patient "deal with it" change it use only generics? 3. I still go to the hospital. Do you simply charge the patient for this or do you have to stop going to the hospital? I am sorry it sounds like I am trying to get a free consult on DIY cash-only practice. I would just like to know.
I stopped reading some of the comments after I read Sermo Doc 24's novella! I'm not sure I agree with every single point you made, but, damn, you are a creative and thoughtful writer. Maybe you should be assisting Dan writing proposals.
I've known a couple of psychiatrists who had comfortable cash-only practices. It seems to work fine for them since patients who finally admit to themselves they need psychiatric care understand it's going to take several (or more than several) visits to rewire their fray of emotions and thoughts. They also may have the insight that the doctor may not be able to fix everything.
In contrast, the FP is expected to fix whatever problem (or multiple unrelated problems) the patients wants addressed. The resentment when we can't may manifest as unwillingness to pay. It would be nice if those in primary care could share specific details of how they have been successful.
Anesthesiologist- no real choice- cash only not practical for the great majority of us.
If 'Public Option' plan is enacted based on Medicare fee schedule, I would guess 1/3 of anesthesiologists would retire within the next few years, and NO medical students would consider it a viable specialty.
I have fee for service practice. I can refer for MrI , etc. and patients' insurance will pay for it. Also for medications.Can also fill out faxes for prior authorizations. Charge the patient for visit to hospital. Hospital charges insurance for stay.
It is hard to understand how two obvious oversights consistently get ignored. Defensive medicine is a problem that gets talked about all the time. But a bigger problem is that doctors are practicing "what's covered" and not what's good for the patient or society. Hypothetically, more stuff being covered as a result of reform could be good for all, even practicing physicians. I don't think any of the politicians are smart enought to understand this, but doctors ought to be.
The second prediction is that with essentially all the people in your practice being Medicare patients, they will have to compel doctors to see them. Doctors ("specialists" especially) won't be able to just dump them back on the primary care docs anymore. This will result in a mass exodus from the business. Broke primary care docs will get jobs as a manager at Applebees (and make more money) The fat cats will just retire--they aren't going to do primary care work or work for primary care wages. Who's going to see all these people???
Thirdly, critics like to talk about the government interfering with the doctor patient relationship. Have any of you folks spent any time refilling prescriptions lately?? The private sector insurance companies have been telling you what you can and cannot prescribe for decades!! Drug reps don't even talk about efficacy of their products any more. They talk about which insurances cover the stupid stuff. Why should we give a crap about what is Tier 1 or tier 2...??? Does it not matter whether the stuff works?? The government did not invent the concept of "prior authorization." Anybody old enough to remember when all you needed was a doctor's order to get stuff done?? WHEN the government takes over, it will be time for many of us to find another way to make a living but hopefully those of you who will still be seeing patients will convince your politician friends who take all your republicam money to make sure more stuff gets covered
Isn't it interesting that all of the blow-hards in Congress (and the White House) just KNOW we will be there to take care of everyone however it all shakes out.
Sermo Doc 56, you are right that the general public should take better care of itself. Unfortunately, prevention rarely saves money.
Let's say my neighbor smokes like a chimney, drinks like a fish, and eats like a pig. At, say, 55, he is fat, emphysematous, and cirrhotic. After two years of progressive worsening of the above, he dies.
I don't drink, don't smoke, and exercise faithfully. At age 70 my yearly PSA shows a rise. My early prostate cancer is cured by resection. At age 75 my annual labs show high lipids. The statin causes rhabdomyolysis, so we finesse that. At 78 my interval colonoscopy shows polyps, which are resected. At 80 my annual physical shows new adenopathy, which proves to be low grade lymphoma. R-CHOP obtains an apparent complete remission, but let's not kid ourselves, that isn't cured. At 82 the lipids catch up with me, I have a STEMI (despite my having legs like Jim Fixx and pecs like Jeff Life). I get stented and am almost as good as new...
By this time my medical care has cost more than my neer-do-well neighbor's. Now, I've lived much longer. than he did. Maybe my general good health has been more enjoyable than a self-indulgent booze-, nicotine-, and fat-fueled haze. But unless I am polite enough to just drop dead with my first illness, my various preventative triumphs will not cost less, they will cost more.
Sermo Doc 98,your point is well-taken but completely flawed in rationale if you remain,directly or indirectly,a productive member of society, till death.Sagacity and the knowledge it passes on in any manner may even be quantifiable,with or without substance.Good point though,if the thought is fixed on a tangent.
I have practiced 23 years and 50 to 70 percent of my practice has been medicare. I think taking cash from this group is nothing short of barbaric. I frankly lose a bit of respect for physician who dismiss their established elderly patients but certainly understand limiting the percentage in a practice and appreciate how medicare reimbursement could be financially deadly for a 1 or 2 person office. The only way I have survvived financially is by having partners or a system that sees higher paying patients, higher volumes, or benefits from the ancillary services medicare patients generate. I have never made even close to the average income of an internist but I have always lived comfortably; nice house, a couple of nice travel vacations a year out of a state, driveable (but not fancy) cars. I send my son to a private school. I have to admit, I started out with no debt.
I enjoy taking care of the over 65 crowd...generally less whiny than younger folks and actually have problems I can apply my skills to and make me think. I feel like I am providing a real service to the younger folks on medicare since they are by definition disabled and chronically ill.
Oh yah! I appreciate that those 20 and 30 somethings that pay well and take 5 minutes...allows me to catch up and make some real money. But as far as pure doctoring goes, give me the medicare crowd any day. I'll either get my reward in heaven or get a huge financial windfall when the rest of you have dropped medicare and the feds respond to the crisis by dramaticallly increasing reimbursement.
barbaric is a strong word. Should docs lose or pay their own money to treat patient's whose insurance puts them at a loss. That is either called bad business or charity.
I'll bet a good number of docs would compete for seniors care if allowed to get paid at time of service, without the bureaucracy. And all medicare would need to do is 2 things.
1) reimburse patients who choose to see a opt-out physician.
2) make it a law that all physicians need to post their fees in a transparent way to increase competition.
as for the feds increasing "reimbursement" in the future to levels that allow docs to not lose money, I say , "what are you smoking?"
1) reimburse patients who choose to see a opt-out physician. 2) make it a law that all physicians need to post their fees in a transparent way to increase competition.
These are brilliant ideas. It will also reduce administrative burden (and cost) on medicare intermediaries and CMS can save money.
1. How do you deal with referrals? If a patient has BCBS/Aetna etc.and they need an MRI, specialist referral etc. how does that work?
when you are not in network, you are not required to do this crap. Seriously. Yes .It was discussed a while back on sermo.
2. Meds - I am constantly pummeled by the fax from the Ins. Co/Medco about formularies etc. Do you just tell the patient "deal with it" change it use only generics?
You do it as a favor to pt. It is upto you how you want to relate to them. there are several ways out - asking pt to fill, charging for filling them, charging PBM for filling or simply refusing to do it. But, remember, these options save money to pt and many times they are forced to use them... so you dont want to tell them to forget about it... you will lose pt. In practice, my approach is to encourage use of Walmart 10$ for 3 month plan. I dont contract with crappy insurance and no medicare advantage plan, so my PBM fax burden is quite small. Also, I have their number blocked so they can not fax it, they have to mail it and so I do not get one copy of the same Q24 hr.
3. I still go to the hospital. Do you simply charge the patient for this or do you have to stop going to the hospital?
Whether Hosp work makes sense for your practice or not is a separate qn and you might want to address that before you try to face qn of charging pt. Quite likely, you will find that Hosp work is a money losing venture for you anyway. Will you lose pt if you dont do Hosp work? I dont. After careful analysis, I devised a crude formula: If your average inpt census of paying inpt is more than Minutes required to reach from office to nearest medical floor/3 you will profit by doing inpt. (as much as or more than what you make in office) .......... if you are not busy in office, its different.
I am sorry it sounds like I am trying to get a free consult on DIY cash-only practice.
If reform restricted amount of earning, I think that the cash only way possible. In expectation of significant life changes adjustment also would be necessary. I think reform may bring regression and eastern european countries learned this tyoe on their own experience. Look even at Canada, where you need to wait 6 month or so to get MRI and people have to go to near by US city to get MRI "right now" for certain financial renumaeration. I think that America may loose a lot of grat physician if income would be limited. As for me, I will switch to cash only practice. I am sure that a lot of patients would suffer in the long run. Eventhough the current system is far from optimal, any changes may impact several generations ahead in time.
As a surgeon in a middle class community with high Medicare penetration 50-90% I would not get very far with a cash for service scenario. The few cash patients I have , uninsured by choice,are some of the most difficult patients. I should have stayed with cosmetic plastice surgery instead of reconstructive. No pay for caring for sick or injured folks. Pretty sad
Glad you brought this up Sermo Doc 103.When patients pay you cash,they expect miracles,they expect to get well stat;if not,they are in your office everyday,like,"doc,you've been treating me but it's not working;I'm still sick".All this,in the waiting room within ear shot of other patients.They literally want a pound of your flesh and want to be reassured that ALL follow-up visits,including those made for complications further down the road is covered by the initial cash payment.Definitely a pain in the you know where:-) I always tell them in a loud voice,that I was not born in Bethlehem,nor was I ever placed in a manger:-)
Cash pay will not happen...patients have a hard enough time with just their co-pays.
All Doctors should "JUST SAY NO to Managed Care" and get off all the plans and go back to the fee for service method and get reimbursed for our hard work...not just pennies on the dollar.
But physicians are too scared to resign from their manage care contracts as they are afraid that their competition will not follow suit and they will lose their patients, etc.
So, until all docs stop participating in manage care, we are screwed.
If we all or most went 'cash only', medical fees would drop like a rock. Comptition would return for better or worse. No more administrative red tape. Pay for ob, surgery, procedures by installments. Hospitals compete for lower daily rates. If the patient is indigent, treat him for less or for free.
A GP office visit circa 1966 was $7.50. Penicillin shot, $1.00. Basic laceration repair, $ 25.00. Patients expected to pay. If they couldn't afford it, cut the fee or do it no charge. Those good days could come again if we could all stand together and make it happen.
how can it work unless every specialist in a given region went cash only? the reality is people will go see specialists "on their plan" that is just what people tend to do.
so as long as some specialists remain on insurance plans, I don't forsee it catching on so soon, unless you practice in a rural area or area with very few specialists.
The systems under consideration, in my opinion, will require that we accept Medicare, Medicaid, and any other government programs our saviors in Washington devise. I would not be suprised to find our voluntary acceptance of any plan as a condition of licensure...Naw, that won't happen.
Eliminate or table the Baucus Bill, BO's Bills and all other Socialist Government Bills..
Pass a Bill for HSA's with tax deductions, free choice, no government control, and Docs can charge/bill Patient directly like Dentists. Patients could pay from their HSA directly with a Debit Card or similar mechanism. The Patient (and his HSA) would complete the insurance/government forms for reimbursement.
No Government control of Doctors or their Practice.
I have had a cash only practice for many years and love it! Admittedly, being in a specialty that is in high demand helps. I decided to quit taking insurance plans when I was spending more time doing paperwork for prior authorizations than seeing patients! It was so hard to get paid! The insurance companies tried to limit care too much. It is just impossible to treat kids and adolescents in a 10-15 min. med. check. When I switced to private pay, the paperwork and restrictions were lifted and I could focus on treating patients how they should be treated. Patients are willing to pay for good care.
FYI...patients still use their insurance. They just bill it themselves, if they have an out-of-network benefit. Almost every patient's medications are still covered by their insurance plan. Only a very few strict HMOs won't cover medicaton written by a doc out of network. Medication is the most expensive part of psychiatric care by far. I still argue with insurance companies about authorizations for medications, but there's no getting around that.
I didn't go into medicine for the profit, Sermo Doc 12. I was the ultimate idealist when I finished med school, and never thought I would get to the point where I would do a 180 degree turnaround and become outraged by the system. What changed? The fact that I am having a hard time paying my student loans back and having enough left over to support my kids. For all the work I put into this, I don't have to be rich, but I shouldn't have to worry this much either. My patients can get out of paying ME by declaring bankruptcy, but I can't get out of my student loans by doing so, and I really don't have a lot of other debt. Something is VERY VERY wrong with this picture, and it is NOT "greedy doctors" who want to sit and eat crumpets and only tend to the rich. Merely wanting to meet one's obligations (the majority of which are STUDENT LOANS) is NOT the same thing as greed.
Sermo Doc 111, good comment! Isn't it truly amazing how reality sets in when you are working your tail off and all you hear from the government and the insurance industry is that we are rich and greedy? What a bunch of hogwash!
There is absolutely nothing wrong with getting paid for your work. And you are correct...something is very wrong with this picture.
ak, youe are correct that there may be "value" in a longer life that may offset the extra cost of the longer life. It may be sagacity, work product, the enjoyment of their grandchildren. But that's an offset, and does not alter the fact that the more diseases we cure or retard, the more diseases we will pay for before death.
There is currently no consequence for insurance companies to withhold payment, deny payment, reduce payment. (At least if there is something theoretical, nothing is ever enforced)
If anyone else purchased services/goods from a business and didn't pay, they'd be either arrested or referred to a collection agency. But Big Insurance gets away with robbery. It's looting from the system, and ultimately hurts patients access to affordable health care.
That's why unfortunately, physicians need to switch to a cash only model, and let patients realize what the greedy insurance companies are doing behind the scenes, and hopefully revolt. It is the only way physician groups will be able to fiscally survive in these dire economic circumstances which are worsening everyday.
I've been listening carefully as President Obama has been defending his health care reform ideas. Although his goal of ensuring access to health care for all Americans is something no decent person could disagree with, I believe the bills that he and the congressional leadership are pushing are deeply flawed, conflict with the best interests of all Americans, and in some ways violate the values all physicians take an oath to uphold.
(continued...see link)
See link for rest of article by Dr. Kelley on Health Reform.
Richard R. Kelley, M.D., is chairman of the Colorado Neurological Institute and chairman of Outrigger Enterprises Group, a hotel development and management company - the nation's 12th largest - that operates in Hawaii and the Asia-Pacific region. EDITOR'S NOTE: This is an online-only column and has not been edited.
Mark my words- the day is coming.
A 'public option' aka expansion of Medicare to all age groups is on the horizon.
Then shall come the word from on high-
Yes, state by state the legislation will be passed-
"If you want a license to practice medicine in this state, you must accept public insurance."
The government will thereby take the cash-only practice off. of. the. table.
The New Socialist Reform Party under BO has deemed that there is no
Quality of Life left in the free practice of Medicine, so it shall die quietly; "Not with a Bang but a Whimper" (TS Eliot-The Hollow Men).
We are the hollow men
We are the stuffed men
Leaning together
Headpiece filled with straw. Alas!
Our dried voices, when
We whisper together
Are quiet and meaningless
As wind in dry grass
Or rats' feet over broken glass
In our dry cellar.
If we want to be paid we all need to drop all insurance plans and let the patient pay us and submit their claim to the insurance company. Let the patient deal with obtaining reimbursement. Has anyone been to the dentist in the last 10 years? they have it right. Pay me now, and good luck getting reimbursed by your dental insurance.
as above I cannot go cash only because the other specialists in the area will still accept insurance. People really don't care about access, they will wait so their visit is covered. 8 years in and regretting every day of it.
I present this take to anyone considering medicine as a career: "It is the same as being president, if you are really smart enough for the job why would you run."
Make Health Savings Accounts universally available.
Instead of taking employer-provided health care insurance, as is done now, individuals could ask employers to give them the same amount of money the employers now spend on their insurance coverage. This would not be cash in hand, but money deposited into each individual's Health Savings Account.
Like the health benefits insurance employees now receive, this money would be tax-free. It could be spent only for health care - say with a debit card that taps into the tax-free Health Savings Account. People would use this money for ordinary expenses - visits to the doctor, immunizations, routine tests, most prescriptions, and so on. Docs would bill the Patient, no one else. Bill the Patient and collect now; the Patient pays from his HSA with a debit card and then he deals with the Govt., Insurance Co., or whoever, not the Doc!
What about big expenses, like a stay in the hospital or a CAT scan ? The Health Savings Account probably couldn't cover those.
But it could cover the low cost of a high-deductible catastrophic insurance plan, which would kick in whenever you incur a large medical expense.
For most people, these events don't occur very often, which is why such coverage is affordable.
The higher the deductible, the cheaper the insurance policy - just like auto insurance. If you want a plan with a low deductible that covers routine medical expenses, you'd pay a lot more.
But that would be the Patient's decision, not a government bureaucrat's decision.
The Senate has an Amendment to remove HSA's...wonder why? Perhaps because the HSA would remove Health Care from Government control?!
As a Triple Board (peds & child psych) resident, I am flustered when it comes to the end of my psych eval and I have to figure out a distinct code so that the Insurance Gods are appeased at my work. I'm so nervous about upcoding and/or forgetting something that I'm sure I undercode all of my pediatrics billing sheets.
So I'm entertaining buying an EMR when I'm done and going cash only. This isn't because of the healthcare reform, but because I got into medicine and have 200K worth of debt because I like making kids feel better and teaching adults and children to take care of themselves.
I'm catching flack about this from some of my more idealist colleagues, but having someone dictate to me what I can and cannot do is infuriating. We'll see what happens...
I just do not know who is worseoff for me and my patientes; medicare or private insurers should simply disapear so that medical care can be dispensed without inteferance.
The only people who really support the democratic plan in any numbers that I know of live in Massachusetts and have to live with a similar plan already so that they want the rest of the country to suffer their same problems.
i would be interested in learning which specialties are best suited for cash only practices? Best geography? And any other characteristic features of successful cash only practices?
I've been doing cash only for nearly 9 years now - a combination or an urgent care and Internal Medicine practice. I have now accumulated over 9000 patient charts (not all are active) - about 60% are without insurance (so much for sipping tea and eating crumpets with the wealthy) and 25% have high deductible insurance. My overhead is about 1/3rd that of other family docs. I have included a link to a letter to the editor of our local newspaper that was also on kevinmd.com a couple of weeks back on how cash only practices can help save costs...if any reader is interested.
I spoke to another ob/gyn about doing "cash only"...Don't know if it would work for our specialty but similar to what others have proposed...
do fee for service for annuals/problem visits, etc. Have a certain amount of practice money devoted to "indigent care" (ie people who can't even afford basic flat fees that wouldnt cover the price of the test/labs, etc)
Do 10-15 deliveries a month (I usually do 30-40) where I could guarantee my prescence at a delivery, 1 hour long prenatal care visits and monthly classes on nutrition, exercise, childbirth education, etc. For these women, would charge flat rate of $5000. This fee would be "global" and include all visits, classes, pager access, etc. The patient would use their insurance for the actual hospitilzation...
Have a small office (or share) with another physician. No coder/biller, one front office person and one MA.
I know, it sounds like i'm smoking crack.....oh well, just a thought
"Can I get off of this ride soon? I'm feeling sick".....
The ART of medicine continues to be invaded by the business of medicine. I suggest we take every opportunity to educate the extern-intern- resident physicians. This decision can be difficult. T.McG.
One of my favorite sayings is "when two elephants fight, it is the grass that suffers". In the current healthcare "fight", it is the patient (the physician as patient included) that will suffer. Unfortunately, the "grass" (patient) does not recognize its plight in this situation. Let us all reason as Physicians for the benefit of our patients and put our political likes and dislikes aside.
Questions 4&5 won't accept more than 1 answer. This is an ongoing problem with other surveys having the same problem.
As an ED doc, I'm a bit stuck but you CAN ask for payment, once you've treated them. We have done that in the past and will likely do it again soon. For most uninsured, it is the ONLY payment we'll get.
I agree that Medicaid pts take advantage of the system because they don't have any co-pay at all. So why not go down to the local ED to ask them about that bump I've had on my leg for 3 months. Don't cost nothin'!
I have no problem taking care of the working poor that have no insurance, who pay me whatever they are able. Most are truly grateful and I got into medicine to help people, after all. However, I am tired of having to practice defensive medicine so I don't get sued after being FORCED to take care of some of these people. You should not be able to sue any doctor that takes care of you during a true emergent situation. Ever notice all of the lawyers on TV offering to "get you your money if you've been hurt..." It's not all there is to the problem but tort reform needs to be part of the equation.
Cash only practice will work very well for Primary care physicians who do not bill for any procedurs. The office visit charges are reasonable. Patients can submit to their own insurance and get reimbursed. This will cut down my overhead for billing and increase my income.
I already have a cash only micro practice. It doesn't help those who can't pay, but there it is. I have been opted out of Medicare for 4 years.... crazy, isn't it? that you have to petition to NOT take Medicare or they can sue you....
I agree with Sermo Doc 111 as well.... my student loans are right next to my mortgage as far as my debt... I may never be rich either and that is not why I went into medicine. My theoretical monthly Social Security check will just cover my student loan expense... if SS goes down, too bad so sad on collecting my student loans when I'm older....
I had a cash-only practice for 4 years. Want to know why it failed? People simply weren't willing to pay out of pocket for good care. I had over a thousand patients by the end of the "experiment" and they took advantage of me by calling and emailing; not coming in for an office visit because of the cost. I gave up primary care altogether and now practice as a hospitalist. There are many more just like myself who just became fed up. The shortage of primary care physicians is going to get much, much worse.
I think I solved the Healthcare Reform question!! We should give every US "Citizen" the same healthcare plan as our elected officials in Washington get!! If it's good enough for them, it's good enough for me!! And while we're at it, I think every US "Citizen" should get the same retirement plan as they get!! By doing these two (2) things, we could do away with social security as we know it now and medicare/medicaid, thus saving trillions of dollars!! Furthernore, I believe all "legally" working US "Citizens" should be allowed to set their own pay scales and vacation schedules. It is my belief, that if our "Public Servants" (our employees) are entitled to these benefits, then we ("Legally working US Citizens") should be entitled to at least the very same benefits as our "employees"!! We could pay for all these benefits by eliminating foreign aid to all countries friend and foe (do we really have any "true" friends?), stop giving benefits to illegals, stop fighting the worlds wars (what are we really accomplishing in Iraq and Afganistan?) and stop accepting all "refugees", who often times don't appreciate our help anyways!!! But, what do I really know??
What's the rush? President Obama spent SIX MONTHS choosing a dog for his family and ended up getting one FREE from Teddy Kennedy. It's the old adage: "Marry in haste, repeat in leisure. " IF one looks at medicine primarily as a business, the facts will show that physicians work for minimum wages and under conditions that would cause any labor union to go on strike. From a risk/benefit analysis, one would be foolish to continue to "see" Medicare, Medicaid or CHIPS patients. I have chosen to leave medicine because it is evolving into something that I am not proud to be part of. Medicare is beloved by the population because they think they get it "cheap" or free. Little do they know and little do they care that physicians are getting fornicated on a daily basis for their "free" care. Votes do count and elections do matter. I'm just glad that I have other skills that will allow me to survive outside medicine. A fortune is to be made finding OTHER occupations for the massive evacuation that is going to occur when physicians finally wise up to the game. I have "head hunters" calling and writing me all the time trying to get me to sign on and pay them money to find another job. The only "growth industry" in America today is government and bureaucracy. How many of us will become "bean counters" and go to work for insurance companies? Caring for patients requires at least a modicum of respect and care from the patients. People seem to "care" about THEIR DOCTOR but generally do not respect or care for doctors in general. "You wouldn't worry about what people thought of you if you realized just how seldom they do."
"I had a cash-only practice for 4 years. Want to know why it failed? People simply weren't willing to pay out of pocket for good care. I had over a thousand patients by the end of the "experiment" and they took advantage of me by calling and emailing; not coming in for an office visit because of the cost."
Dr. Frank: The solution to your problem would have been to obtain a retainer up front, or charge a yearly fee that included email and phone consultation.
Medicine, in general, should be a cash only business. It is ridiculous to say that the more a certain population NEEDS a certain commodity, the less it should cost. A statement like that means that the more useless the service is that one provides, the more one should be compensated for it.
If a patient believes that the care a physician provides is important and improves his quality of life, his functioning and his ability to deal better with the world, he should then be expected to pay for what he gets. Accusing doctors of charging 'too much' for the life-saving help they provide, is worse than going into an expensive, upscale restaurant, consuming a sumptuous meal and then demanding to pay only what it costs to buy an extra-value meal at McDonalds, simply because the person 'needed' the food.
One person's need is not a valid claim on another's effort.
This is the free market model. One that I fully support. It does carry responsabilities for the providers, as we need to post our prices in a clear way so that patients can figure out how much their care will cost them. They should be able to compare among physicians and providers in general for the best value for their money. We need to be more open about our outcomes, so that patients can decide who they wish to see. It does not mean, the end of insurance companies, as they can also get involved in the competition by providing High deductible plans, which will allow patients to get a Health Saving Account where they can withdraw the money that they need to pay for the expenses until their deductibles are reached.
They've got rural eye docs by the you-know-what's. Very little wiggle room when 70% of revenue stems from M'care and/or M'caid. Our practice would most likely first consider dropping Medicaid (if it is still legal to do so), which would be terrible for our area since around 45% of all kids in Georgia are on Medicaid. Let's face it, however, if we dropped Medicare, some one else will take care of those patients - maybe not as conveniently, ethically, or as well - but it will get done. I do foresee, agreeing with others in our field, a shortage of ophthalmologists in the near future. For those short-sighted enough to not realize the huge difference, optometry may seem to provide a solution to the ophthalmoloigst shortage; but, going back to the Medicaid and kids example I used above, it's hard to find optoms who will see Medicaid in our state.
I am also concerend that another blank check will be handed to the consumers of health care and the party that will bear the logistical and legal burden of gatekeeper and rationer of care will be the docs.
IBD stands for Investor Business Daily, a newspaper similar in many ways to the Wall St. Journal. It conducts polls, similar to those done by WSJ, ABC, NBC, etc.
I have tried for several minutes online and am embarrassed to admit I cannot determine what TIPP stands for.
This must be TIPP since it's not a disease! TIPP is IBD's poll??
IBD/TIPP Doctors Poll Is Not Trustworthy
by Nate Silver @ 11:58 AM, 9.16.2009
Share This ContentI'm flying 35,000 feet somewhere over Eastern Ohio now -- isn't technology wonderful? -- so I can only comment on this briefly, but the Investors' Business Daily poll purporting to show widespread opposition to health care reform among doctors is simply not credible. There are five reasons why:
1. The survey was conducted by mail, which is unusual. The only other mail-based poll that I'm aware of is that conducted by the Columbus Dispatch, which was associated with an average error of about 7 percentage points -- the highest of any pollster that we tested.
2. At least one of the questions is blatantly biased: "Do you believe the government can cover 47 million more people and it will cost less money and th quality of care will be better?". Holy run-on-sentence, Batman? A pollster who asks a question like this one is not intending to be objective.
3. As we learned during the Presidntial campaign -- when, among other things, they had John McCain winning the youth vote 74-22 -- the IBD/TIPP polling operation has literally no idea what they're doing. I mean, literally none. For example, I don't trust IBD/TIPP to have competently selected anything resembling a random panel, which is harder to do than you'd think.
4. They say, somewhat ambiguously: "Responses are still coming in." This is also highly unorthodox. Professional pollsters generally do not report results before the survey period is compete.
5. There is virtually no disclosure about methodology. For example, IBD doesn't bother to define the term "practicing physician", which could mean almost anything. Nor do they explain how their randomization procedure worked, provide the entire question battery, or anything like that.
My advice would be to completely ignore this poll. There are pollsters out there that have an agenda but are highly competent, and there are pollsters that are nonpartisan but not particularly skilled. Rarely, however, do you find the whole package: that special pollster which is both biased and inept. IBD/TIPP is one of the few exceptions.
I have posted on this several times in the past. I am a psychiatrist, solo practitioner, who 9 years ago resigned from all the insurance networks, and 5 years ago from Medicare. I provide Fee-for-Service care only. All new patient appointments are scheduled by me and I explain fees and billing and no show/late cancel policies to the patients myself. And they sign a paper stating they understand the policies. My patients expect I will give them my undivided attention in their appointments, will explain risks/benefits and alternatives about their treatments and will be available by phone for true medical urgencies only. They understand they are paying me for my time and expertise. Likewise to provide cost effective care I expect patients to be compliant with treatment recommendations, to attend appointments as scheduled and to do homework if assigned. So, I expect motivated patients who care about getting well. It is my experience that if it is costing you money out of your pocket, it makes you a better more motivated consumer of health care. Some patients do not stay, choosing instead to see someone for a "$10 copay." Not infrequently these same patients are back, dissatisfied with the care provided by that $10 copay doctor. I will never go back to being an employed physician or beholden to the rules of managed care companies and insurance companies. I will leave practice first. One might argue not everyone can afford my care. I would argue that where there is a will there is a way. My favorite example is a medicare patient who asks her nephew each year for a visit to my office as her Christmas present. Not a bad gift!
How are patients best incentivized to engage in health-promoting behaviors? Having to pay cash for office visits will likely cut down on "nuisance" visits (e. g., the young healthy adult with a viral syndrome) but may also reduce compliance with recommended prenatal and well-child care, as well as screening and chronic disease management. These preventive interventions are essential to maintaining optimal health and should ultimately decrease costs such as hospital readmissions.
I read a few months back an article which quoted that $9 billion annually is spent by physicians for medicare and insurance billing "clearinghouses." What could we do with that money back in our hands?
totay is OCT 1 MILLIONMEDMARCH.. look to see if any NEW MEDIA of the STATE RUN PROPOGANDA even pays attention to US
great news today in for emergency Dental surgery today... Snow birds to TEXAS are saying you can ONLY get DOCS who are CASH ONLY !!!! GO TEXAS and SAVE THE UNION from Communism!! the biggest joke with current health care reform is to TAX those who HAVE DECENT health care to pay for those who do NOT!! Erode the health of those working with Insurance to "help" those who , here , anyway , REFUSE to go to where there are JOBS!!..
Interesting question. The debate and questions on this site are biased towards criticism of reform. This one shows relatively little bias. I know several psychiatrists, mostly younger and from backgrounds that allow them to gradually build their practices, who are building cash-only practices in my region. This is all well and good, but I fear it does little to deliver care to those who need it most.
Sermo Doc 12 If you went in to medicine to care for the poor underserved as you say, then you would oppose this plan to decrease the quality of healthcare for all. Right now the poor get much better care than most hardworking Americans because the workers support the system with tax dollars to the point that they cannot afford their own healthcare. I see them both and we are paid diddley squat by the gov't and now insurances also and the poor hard working middle class sap pays a full overinflated price to subsidize everyone else. I am sick of watching it and sick of hearing bleeding hearts that can't see the forest for the trees. However, in resignation I am afraid that we have gone too far to stop now until we bankrupt the system, much like the USSR did in another way. You can follow them off the cliff. My answer is to Buy Gold, Treat for chickens and go to the medical mission field where we can really make a difference.
Many primary care docs in our area have switched to cash only, concierge type practices. Others have stopped taking new Medicare patients, and very few take any Medicaid at all. We are now seeing many more of these patients in the ER because they lost access to their physician and cannot find another one, and simply cannot afford the $100-200 for an office visit. I'm all for a cash only practice,and I actually believe that we should collect for non-emergent visits in the ED at the time of the visit. I also think that catastrophic coverage is the only real use for insurance. However, we need to make office visits more reasonable if we expect patients to get care in an appropriate manner.
"However, we need to make office visits more reasonable if we expect patients to get care in an appropriate manner."
As more and more physicians refuse all insurance payments and accept cash only, competition among this growing supply of physicians will lead to lowering the price of an office visit.
We are the ONLY profession that, when we increase our fees, we do not get paid any more because of insurance contracts. So when our expenses go up, it erodes our bottom line, unless we see MORE patients and spend less time with them.
YET without us, the insurance companies have no service to offer. If enough of us said NO to insurances, we could ALL go back to fee for service.
Stuck between a rock and a hard place... like everyone else: I've refused to be bought by the local hospital and then be pimped; make less than half of what a typical first year out of residency could make; am still in solo practice, see my bottom line swirling the drain rapidly; am about to refuse anyone over the age of five with medicaid (stopped seeing new adults with medicaid five years ago due to economics), will most likely have to stop taking new medicare soon; was just told by big blue that they are not going to pay for specific services rendered that have been covered till now - oh, by the way, that will be retroactive to LAST October (1/4 of my gross billings for the past 12 months), etc, etc. Add all of that to living in a very poor community = how could I survive on a cash practice? I've played with calculations on how to go cash for years. On the other hand, how can I survive with insurance the way that it is? Caught in a lease for my office that I can't break for 3.5 more years, so I can't move.... Sermo Doc 140, I'd head for the mission field in a heart beat, but my husband refuses. Grew up on a hospital mission station, figured that's where I'd return. It's still tempting, but then it's the choice of my marriage vs. mission field.
I'm all for SOME type of reform, I just haven't seen anything that I think really could or would help. It's the infamous Catch 22.
Has anyone here actually tried SimpleCare.com?
Friday October 2, 2009
Welcome to SimpleCare.com, home of one the largest patient/doctor organizations in America. Here you'll find a host of resources, links and contacts that will help you take control of your healthcare situation. If you're a patient looking to cut your healthcare costs but get better care, SimpleCare is for you. If you're a doctor looking to practice medicine your way while also getting fair market value for your services, SimpleCare is for you too. And if you're a business owner struggling to insure your workers, SimpleCare has what you need. Better care for less money - it's just that simple!
How does it work? We call it PIFATOS - Pay In Full At Time Of Service - and it is truly a "Cash-Based Revolution." A patient sees a doctor for a non-catastrophic reason - yearly check-up, a nagging flu, a twisted wrist, an aching stomach, etc. The doctor bills the patient after the visit. The patient pays in full before leaving. Because doctor charges are anywhere from 25 - 50% inflated due to administrative costs caused by the health insurance industry, you'll be paying drastically reduced rates for your medical expenses. In conjunction with a regular catastrophic health insurance policy to cover extremely costly procedures, PIFATOS can save the average healthy adult and/or family up to $5000/year!*
Now, ask yourself. How often do you go to the doctor? And when you do, how long does it take the doctor to treat what you have? The fact is, most healthy Americans don't visit the doctor all that often for non-catastrophic reasons, and when they do, they don't visit with the doctor for all that long and they don't receive very elaborate treatment. So why are most healthy Americans paying huge sums of money to insure themselves against regular doctor visits that actually aren't that expensive? They shouldn't be, and with SimpleCare, they don't.
I believe SimpleCare is THE most powerful solution to the problems plaguing America's healthcare services, and I trust you'll believe so too once you browse through our site. If you have any questions, feel free to contact me. Together, we are changing the way America stays healthy!
To Health and Wellness!
Vern S. Cherewatenko, MD, MEd
Founder & CEO, AAPP/SimpleCare
Already switched to cash-only. Many patients desire more than a 5 minute visit for a little more out of their pocket. I know that this will continue as long as the government doesn't require that I contract with government run programs in order to keep my license - this is my fear. Didn't go to medical school to become a government employee - did you?
We have a very specialized quaternary private practice and are always in discussion about switching to cash only. We have high overhead and even now only break even on Medicare patients. One problem is that we have a subset of patients (minority) with one very bad, severe diagnosis and typically little money. They're usually disabled and have Medicare. Since we have the most experience in the world with this group, we feel a duty to care for them, even at a loss.
If things get rough, the best solution for us would be cash only for most diagnoses and accept Medicare/Medicaid for that group noted above. I would even consider cash only for most patients and charity care for this group.
I hope that I am not forced to give up care of our most needy patients in order to run a viable practice.
As a young pediatrician myself (just starting out, so salary is not all that great) with a young child I am grateful for having health insurance provided by my employer. My son is 14 months and between the well child visits, vaccinations and sick visits for fevers, otitis, etc.. the thought of having to pay out of pocket for all those vaccines and visits and then trying to submit claims to get reimbursed or just sucking up the cost if I did not have insurance is annoying. I can only imagine what it would be like for families with young children who do not earn as much. When you have a young family, having insurance only to pay for "catastophic events" is not enough.
Sermo Doc 146: Did it ever occur to you that one reason your "salary is not all that great" is BECAUSE your employer is paying for your health insurance? It's NOT a "free lunch".
Dear Colleagues, I just looked at this topic on cash paying clinics to see if there was something that I didn't already know about them and I found evidence of one of the biggest problems in medicine-doctors themselves. We back stab one another, we pit specialists vs. primary care, we dislike midlevels until we can figure a way to make money off of them and do less work, we started taking insurance contracts at some point and signed up for medicare and medicaid because we were told to do it in residency. We pay riduculous fees for malpractice insurance, so we have to charge fees to pay our staff, light bill, rent, supplies, insurance, telephone,security, and now we have to have a platoon to collect the money we bill insurance companies.
I grew up in a democratic household, and if your not democratic when your 18, you don't have a heart, but if your still democratic when your 40, your stupid. My democratic friends always want to save the world ,but with someone else's money. Let's implement catastrophic plans for hospitalization and real emergency room visits and start health savings accounts for outpatient services. We then can get out of the insurance business and get competitive in the doctoring business. We also need to get some serious tort reforms. When our overheads are low, and we don't have to run patients through like cattle and we can afford to have our own practices and not be bought, and bound and gagged by hospitals buying our practices, maybe just maybe we will not be mad at every patient that comes in with a 8x10 list of problems and will set the price according to what we do for them and not some false 99213 code, but maybe a flat fee for 3 or less problems, and have menus with real prices, so the consumer will know what things cost. Competition will drive down prices and people can cross state lines to ge the care they want. I had a cash only practice 3 years ago, and it doesn't work for two reasons1. 80% or more people have some kind of insurance , they don't know a damn thing about it (such as deductibles, prevention coverage, copays, etc.),but they want to use it, and then they scream when they get a 200,00 bill because you have to bill them after it goes through insurance and 2. the persons that did show up to this beautiful cash pay clinic never had the 45.00 to be seen and stiffed me. I had to go back to insurance. It doesn't work unless your in a predominant hispanic or amish area and have this population that also like cash pay. Insurances are killing the doctors. One thing I will mention is that the book by Ayn Rand-Why Businessmen Need Philosophy will open your eyes to what is taking place in this country as we speak and I for one am not going to sit on the sidelines any longer. One of my partners is a State Rep and is going to run for the Senate- he has a good heart and is a very good patient advocate. We need to go back to having charities and us being a part of those for people who cannot afford anything. Also, I can't be expected as a family doc to charge 45.00 OV when my GI, buddy charged one of my patients 800.00 for a 5 min. no hands on pre-colonoscopy visit. What is that? Pathetic. I've went on enough, but lots of good people have made comments and most are very interesting. Good luck everyone. Dr. Deb
I would love to go cash only, but in my area that would just drive patients to other docs and force me to use a collection agency. However, I think it might be feasible if you already have a large (loyal) patient base, provide ample advance notice, and utilize hospitalists for in-patient care.
Reminds me of when I had a kidney stone. I called my "insurance" company to find out what they paid for a CT w/o, and asked where it was cheaper for me to go to. THEY couldn't tell ME (their freakin' customer) that because it was privileged info.
Obviously, I wasn't in excrutiating pain (more worried about some other pathology, with the discomfort and microhematuria), so I called about 5 imaging centers. Talked to their office managers. (No, I didn't tell them I was a doctor). Found the cheapest ones, and then called all of them AGAIN and negotiated. Finally asked the last one "OK, what if I bring $20 bills?" and got another 10% off.
Ended up being 20% less than what my insurance would have reimbursed.
Unfortunately, most patients don't have the knowledge and skills to be able to negotiate their care including expensive procedures like CT's. Many don't live in areas where there is an option to negotiate.
Is there someone out there who'd like to form a private doctor owned, non-profit company to negotiate or barter these services (like the really old days), i.e., "BarterbyDocs.com", "DocsforYou.com", or "LowcostDocs.com"? I'm sure you all have better names for such a service but there are companies out there that already provide this kind of service like:
Medical Cost Advocate (MCA):
Medical Cost Advocate provides health care cost reduction solutions to benefit consumers. Medical Cost Advocate is the expert source to validate billing accuracy, negotiate medical bills and regain control over your health care costs. We can reduce your medical bills after services are performed or reduce your procedure price before services are performed.
Done the math--take my current solo family medicine practice, est 4000 patient panel, est 22-25 visits per day, overhead eating up >65% of collections (which are only 68% of charges after insu, mcaid, mcare discounts)
If only 10% of my current patients give me $1000 each at beginning of each year, I could do everything I do for them now--checkups , visits, minor in-office surgeries, even "give away" the lab work, and just tack on exact cost of high ticket items like vaccines, as a convenience. Huge reduction in overhead, including staff. I'd be making two times what I get to keep now, but would have less than 8 visits per day, have more time to myself, wouldn't have to deal w insurers. Patients would need to keep Major Med for catastrophic care, and high deductible (set aside what they'd save on too high premiums for the ppo/hmo ins they've got now into HSA's)
BUT, if we all did this, who'd take care of the other 90% of our patients?
Reguardless of the maner in which "reform" occurs, if "THEY" don't compensate doctors fairly, ie: stop medicare paycuts, fix flawed MC formula, (all insu links to medicare as a percent one way or the other) allow for increase in compensaton to keep up with increase in the true costs of running office--or I may be crazy enough to go cash only, and so may a lot of other PCP's.
Sermo Doc 150,
I just received a mailing from a Doctor in my area doing exactly as you outlined. He's trying to recruit new patients but I don't know what success he's had or how much he's charging per capita.
I also know of several other Docs in State who are doing the same thing.
If nothing is done by Congress to reform the current system without gov't. control, then it will be survival mode for those who want to stay in Medicine!
Good luck to us all.
I am so proud of the conversation going on here. It makes me believe in the power of doctors and our desire to be good ones. Lets start abitration contracts in our offices right along with theHIPPA signature we have to get. That way the patient would have to sit down and talk with us before sueing us. What do you think?
Sermo Doc 147,any and all contracts signed by your prospective patients before you care for them is void if a lawsuit occurs.The trial lawyers(read:the law)assumes coersion or that such a contract was signed 'under duress'.Go figure.
The good doctors who answer to a higher calling should understand the critical notion of "no money no mission" if you can't pay your rent and staff you won't be privilaged to share your compassion with your patients unless ofcourse you work for others that pay you a fixed salary while they manage budget.
If we gradually withdraw from all insurance contracts, starting with Medicare/Medicaid, over the next 2 years, then that will give both us and our patients time to adapt. We should all DITCH CPT codes, ICD codes, and all other such worthless resource-eating bullshit we've allowed the government and insurers to impose on us, and present bills in plain language.
We should just tell our patients, "if you want your insurance to reimburse you, then send them the bill with a request for reimbursement." Of course, initially, none of them will be reimbursed. But as more patients demand insurance that reimburses our de-bullshitted bills, then insurance companies (and maybe even ultimately Medicare, who knows?) will respond with insurance products that make sense.
In the meantime, WE WILL BE FREE from all the ridiculous interference we've only tolerated this long because it was inflicted on us in such a gradual, insidious manner.
Stop Thinking Insurance
How to implement health care reform that cuts costs and improves care.
www.forbes.com
If the government continues to make me jump through more and more hoops or place more unfunded mandates and demands on me, I will just say "To hell with it" and either stop seeing Medicare altogether and concentrate on cash only or retire outright.
Patients often complain that we don't spend enough time with them and that "doctors don't really care about me."
Well, I have this radical proposal, pay me by the minute and 'll spend all the time you need with me. This would not only bring up patient satisfaction but also create responsibility on patients part, where they will now have a check list of things they want to talk about, not bring 10 other kids in the room while you try to explain something, turn their cell phone off and perhaps even show up on time to their appointments, etc. What do you think?
Need to think about going back to paying for office stuff and only using insurance for big ticket items. Need to look at how pharma prices drugs and makes its profit all in the US. Need to stop paying the guys at the top such big salaries. Need to get rid of the rediculous paperwork for insurance.
Had to precertify a brand on birth control pills today because a patient was bleeding on generics. Actually had to fill out the Medwatch form. Pisses me off. And, of course, no reimbursement.
On the other hand, if you are a physician who engaged in this profession because you felt that you had a higher calling, one that involved caring for those in need regardless of their ability to pay, perhaps you might re-think your opposition to changing the pitiful status quo. The people of the United States deserve access to health care and the current system limits that at almost all levels.
Sure, we need to figure out how to stop wasting resources and make the reformed system work. But waiting for the perfect solution makes no sense. Put something in place, fix the most egregious problems, and let it evolve. In other words, "lead, follow, or get out of the way:.
Insurance should be for those medical catastrophic events that few can afford. Just as we don't bill our homeowners insurance for routine maintainence...we shouldn't use health insurance for this either.
The culture of health care purchasing would change. Patients would begin looking for value and start to understand how to avoid the wasteful practices that we all see daily.
People would realize that it makes little sense to go to the ER for a sore throat or a backache. We may begin to infuse some common sense into an otherwise nonsensical system, where the customer and the provider of service are both blind to the costs.
If one can pay cash for his/her food at a grocery store, why they cannot do the same for their healthcare???
HOWEVER. . . there is room for reform. Sermo Doc 12, you miss the boat if you think that practicing medicine for the sake of altruism vs. as a way of making a living are mutually exclusive, and I'd be willing to bet that as a pulmonologist, you collect a sweeter salary than mine as a small town general surgeon. Few of us have the luxury of practicing medicine out of the goodness of our own hearts. If there weren't people who understood business in medicine, we wouldn't have any medical practices in our country as we wouldn't be able to afford having any of them!
What we need is to curb the waste in our practices which is, to the overwhelming majority, due to LAWSUITAPHOBIA and GOVERNMENTOMEGALY. You can't jettison the obnoxious patient, tell the family of grandma beth who's suffering from the last stages of dementia or stroke that she doesn't need to have her colon cancer excised, avoid taking the vented patient with metastatic cancer to the OR because they're going to die and their family isn't psychologically prepared for it, or deny care to the IV drug user with their 4th round of necrotizing fasciitis without fear of getting sued. It's become cheaper to throw out EVERY piece of equipment (from drapes to instruments) as it's more expensive to reprocess them due to fears of a suit. LOOK at a patient or their family wrong, and you'll get dragged into court. Your paperwork takes twice as long to complete because you have to document every comment, every pimple and every thought lest you get sued, or - even better - you may not get paid by medicare (which is the standard that all insurance companies have sunk to). Even your H&P has to be twice as long as it needs to be because of these same considerations. Do I really care when my IV drug addict had their last colonoscopy???
In short, we need TORT REFORM, and greater accountability to and by the patients for their care. I would LOVE a cash-only system, as my most responsible and frugal patients are the ones who bear at least a good chunk of the financial burden themselves. We need a GOVERNMENTOPLASTY to reduce the pannus of paperwork hanging over our heads that takes time away from patient care, and has the government determining the lowest common denominator for all care and payment - Obamacare would do just the opposite. Let me accept cash payments at a reduced rate without getting fined by Medicare for doing so! Let us get tax credits on the myriad of free care we provide to the indigent! Give tax credits to those with good insurance instead of taxing "cadillac plans"!!! Yikers. We need PATIENT RESPONSIBILITY for their financial expenditures with limits on care (yes, LIMITS) or increased financial responsibilities (yes, FINES in the form of non-waiving of copays) on preventable items such as obesity, smoking and drug use. We need to set some LIMITS the end-of-life care we provide to terminally ill patients - not through "death panels", but through a transfer of financial responsibility to the family/patient beyond some level of care. We need COPAYS for patients who visit the ER, especially if they're on Medicaid or self-pay to prevent abuse of our overly taxed ER's. Finally, we need some redefinition of the payment-to-risk ratio. If you don't pay me anything, you don't get to sue me unless there's GROSS (and I mean gross) negligence.
Spare us the "fix it or get out of the way" rhetoric. There are plenty of people suggesting what I've suggested (look up the Ryan amendment from 3 weeks ago), but nobody in the government is listening - especially the ones in power, who are more concerned about getting themselves "known" and re-elected than fixing our indulgent, entitled nation.
If patients were required to think about their health care rather than simply run for treatment for every ache or pain, then they would also begin to think about how to avoid illness in the first place. If patients had to pay first dollar coverage rather than relying on the insurance companies to cover everything, then they would also begin to balance the necessity of treatment today vs the advisability of waiting a few days which, as we all know, cures many ailments, and they would be able to give due consideration to the costs of preventive care vs the costs of none. If patients knew they needed to pay their physician up front, they would develop savings strategies to cover such an event rather than relying on "somebody else" (or no one) to pay when the time comes. If patients had to purchase their own insurance then insurance companies would begin to compete for covered lives on the basis of clarity and efficiency rather than on their ability to peddle favors to large employers while screwing small ones. If patients had to apply for reimbursement to the insurers whose premiums they paid, insurers would begin to streamline their reimbursement procedures to avoid losing customers, instead of delaying and denying for extra profit as they do today. If patients knew they had to pay up front, they would take the time and effort to shop for inexpensive, efficient care instead of shopping for amenities as they do today. If providers knew patients had the means and the incentive to shop for care, they would find it necessary to reduce prices in order to compete for customers. If patients paid cash for their care they would receive a more in depth interaction with their physician and a higher quality of care, allowing less frequent visits with a better outcome and less overall expense.
Several things need to happen to make a cash system work. Providers must be required to post prices. Insurers must be required to accept all applicants. Patients must be required to carry insurance. Tax incentives must be moved from employers to individuals. Ideally, insurers should compete on a nationwide basis. A safety net for the poor must be reconfigured, and a punishment/incentive system must be established for those who refuse to obtain insurance. All these things are doable, and many/most are already proposed in existing pending legislation.
Medicine is indeed a higher calling, and you should be ashamed for advocating for a system which is certain to serve patients poorly in a mass production environment. People are more complex and more fragile than steel or plastic, and the reason medicine _is_ a higher calling is because of the realization that they need special handling and sensitive interactions. Assembly line medicine, whether run by corporations today or government tomorrow, offers none of the "care" which defines medicine as the higher calling it is; it offers only rushed, one-size fits all service at the cheapest commodity price. If you want it, I sincerely hope you can have it - but it won't be provided by me.
Sermo Doc 12 - Does feeling a higher calling mean I should be trampled upon by insurance/management organizations, government and, yes, even patients?
I recently told US Senator Michael Bennett that just because the AMA supports socialized medicine doesn't mean that doctors in general do. He can pass a plan, but if 40-80% of the practicing doctors go on strike, it won't do a damn bit of good.
1. Medicine is a business like any other. Much of our time is spent in the healing mode, but if you don't bring in enough dollars in any given month, you close up shop just like any other enterprise.
2. Politicians don't understand point 1. They also don't understand that simply providing health insurance, doesn't mean that you'll get medical care. Our local US Representative thought that all docs took all insurance all the time. He doesn't have clue that docs can/will pick and choose what insurance to accept.
3. Based on my observations and reading of the bills put forth by Congress, any major changes in our current system (which needs changes, like getting the heavy hand of the Feds out) will result in a two tiered system for Americans. Most Americans aren't ready for this massive change. I predict that their dissatisfaction will be most evident in the 2010 elections. I can hardly wait...
4. Changes made by the Feds WILL reduce reimbursements across the board (just read what the the Congressional bills state!).
5. You will see more cash only practices when the dust settles on the whole system (after Congress is done tinkering). Hey, if you're going to make less money anyway, you might as well go for cash only and save on the paperwork headaches....
6. Why would we want more gov'met involvement when they can't run what they have now (Medicare and Medicaid are financially insovlent). We have knuckleheads running things in Washington DC.
God help us all.
Just say No and drop participation.
Educate your patients. Reduce your fees to a fair level based on your community. Show your patients how to get reimbursed.
I went cash + traditional medicare in January 2008.
Unless forced to go back to insurance, I will never ever go back.
And for the docs who say that cash only is only for the rich patients, that is untrue.
patients who value your services, and trust that you are looking out for them, willpay, as long as your fees are fair. Much easier to do in primary care than specialties, but it goes a long way in terms of building trust.
The second year of my transition, I switched to a prepaid yearly fee, with no copays, and with an option for auto-monthly-bank drafts for people on budgets.
My patients on this type of plan range from business owners, self-employed, to teachers, Walmart workers, and unemployed.
My fees are fair and I spend extra time and build trust.
So there is no reason why you can't collect a fair fee from patients directly without being called names from other docs.
I opened up a bunch of mail today with some EOBs and I just cringe (not the least of which is from denials) but from those that were paid: sometimes 45% of what my fee is!!!;
Dropped a bunch of HMOs but still taking Medicare, and the 4 big ones in this area (tricare, anthem, UC, Cigna) and they all suck but I cant seem to get patients in the door - have lost a lot of patients that I have taken care of for many years;
Why is oral and dental health any different than overall health care? If they were able to do it and have that model accepted by most patients, then we certainly should be able to do so as physicians.
So here is my answer to the question. I assume that there are many docs who would prefer cash only, but we have very few who can make a go of one because people are cost sensitive and don't want to pay out of pocket if the might only get partial reimbursement or have a hassle for reimbursement or whatever. It is useful to remind folks that one of the major sales points from the health plans during their biggest growth period was "no claims forms." If everyone has to have coverage the people who now do pay cash will no longer have to. I believe there will be less of a pool of peop[le willing to pay cash or front the cash. I really think there will be a very small number of docs who could maintain a practice of up front payers. Does one really think that a lage population of patients would agree to paying more, or even fronting the money and filling out claim forms if there was another option?
UNIVERSAL HEALTH CARE WITH NO NEW TAXES
Healthcare decisions should be made at the bedside, not in the boardroom.
Let insurance administrators count the beans, but not consume them. They bring no value and neither know nor care about patient care. Corporate profits siphon the funds needed for the uninsured. More than $700 Billion (30-50%) is wasted every year on inefficient administration.
A better, uniquely American system is simple, practical (already proven and in use), and reduces overhead $Billions while it also provides universal coverage at no increased cost. Capitate the whole system under one budget and to prevent overruns, employ an actuarially designed automated daily adjustment in rates of payment for all medical services, drugs and equipment. Excesses by any party-trending over budget will impact all providers who will spontaneously and vigorously monitor and remedy from within Medicine. Congress should exempt anti-trust impositions to promote collaboration and efficiency.
Organized Medicine (AMA, CNA, Specialty Groups, AHA, PHARMA, etc) should collaborate and negotiate for efficiency and quality. Committees already widely established within organized medicine can provide peer review of claims to monitor accuracy, integrity, utilization and quality. Electronic data base monitoring will provide random and selected—focused oversight. Data management and Payment should be digitized and distributed electronically
Please see www.GoodMedicineAmerica.com for more information. Or call
Carter V. Multz, MD, FACP with insights from 46 years of practice and managed care administration.
American Medicine MisManaged Care.
How we can Improve Quality, Add Pharmacy and have $Billions left over.
By Carter V. Multz, MD FACP, FACR (Amazon.com)
www.GoodMedicineAmerica.com
E-mail doc@GoodMedicineAmerica.com
408 531-0940; 800 800 9111
Patients, with rare exception, pay at the time of service. My fees are substantially higher than the community average. My collection rate for office services (as opposed to hospital consults), exceeds 98%.
In spite of my high fees, my patients do not spend very much on health care; MI's, CVA's, other serious infections are rare in my practice. While my patients suffer prostate and breast cancers, they do not lose breasts or die from prostate cancer.
Higher than average fees allow me to keep my schedule open for patients that are sick or worried. Scheduling 90 minutes for a new patient or 60 minutes for an annual checkup allows for unhurried assessment, communication with referring doctors and appropriate follow up.
I have been practicing in this way in a heavily managed care environment for 25 years and I love it.!
Medicare pays $550 for a scope, $800 for a lami and $1100 for a total joint; my malpractice is $150K/yr. I took a look at these numbers and decided that I didn't want to do 5 cases per week, just to cover my overhead; so I quit doing surgery; a decision made by 5 colleagues I know who are also in their early 60's. The only people operating now are the young guys who can do 10 -15 ops per week (with soft indications) and the academic guys who are subsidized by their hospitals.
Despite training 20% of the nations residents, NYS has an Orthopaedist shortage. 6 counties have no Orthopaedist, 7 only one and 13 only two. Thus 1/3 of NYS counties don't have enough Orthopaedic surgeons to legally run a trauma service.
Patient care is definitely impacted; I expect the whole system to collapse shortly.
I spend two hours with new patients and help them improve their health through changing their lifestyle. We often help our patient reduce their weight, cholesterol, blood pressure and blood sugar WITHOUT meds. Many of them could see their other doctors for a small copay but choose to come to us because they feel our services are worth it to them. We reduce fees when we can for patients who can't afford our fees.
This is the only medicine that makes sense! It is really reform because it ultimately lowers healthcare costs (as opposed to the high tech and expensive, pharmaceutical, procedure oriented medicine). If the government needs to be involved, let them contribute to low income patient's medical savings plans. That way everyone knows directly what they spend and can participate in making sound medical decisions.
For me-
PROS: No more insurance paperwork, less staff requirement, more time with patients, limited practice size, finally making a profit after 15 years.
CONS: Having to "market" the concept to patients (initial front-end investment).
For patients-
PROS: No insurance hassles, denials, delays. More time with physician, better service, less wait time, NO copays, NO office fees, perhaps choosing a more cost-conscious approach to purchasing health insurance for meds, hospital/ER and perhaps specialists.
CONS: Up front cost (usually less than their deductible would be under current insurance).
Encouraging med students and residents to think this route will increase the interest in primary care, as they will be able to see financial gains with their first year in practice, perhaps above some specialists. More primary care PHYSICIANS (not simply "providers") with smaller practices will allow better primary care, decrease useless referrals (freeing up specialists to devote time appropriately to cases requiring their expertise), decrease hospitalizations, and perhaps force the industry to take a look at the disproportionate cost of MANAGING health care rather than PROVIDING health care.
I did not take medicaid and hmos. and some of my best Patients were those who PINCHED pennies for quality and actually WORKED with ME to get better!!!!! I stopped Medicaid WHEN the cost and time of rediculous paperwork far exceeded the paultry reimbursement from Medicaid........I discussed in generalities cases with hospital docs.. over the phone.. as to how I would treat My family in certain situations... .. to further educate them.. The hospital docs were very grateful for this! and never took advantage of me.. It was part of their ongoing ed..........SOME specialists will be hard to get away from government mandate to see all in ER etc.. but the rest of US can create sanity for the majority of patients.... I TOLD UNINSURED patients.. that , even if I was cash.. THEY MUST HAVE CATASTROPHIC INSURANCE in case needed hospitalization............. Some of my medicaire patients spent more each week on GOLF than on health care........ at some point , when they value their care , they WILL GO TO CASH.. and not be caught up in "the GENERAL style CLinics.
and the the YOUNG DOCS>> , they must quickly get out of DEBT so they can free themselves of THE INSANE GOVERNMENT AND LEGAL SYSTEM. who have both become equvalent to the EBOLA VIRUS.. I do hope this SICK Infestation can be HEALED with getting them away as they are absolutely INCOMPETENT in even being associated with medicine.
A few of my own thoughts:
1) "Cash only" doesn't necessarily need to be only for the rich. For office visits, education, counseling and the like, rates can be comparable or less than other professional services and (if not prevented by regulation) one can have some pro bono work either in the practice or through local foundations/charities.
2) The keys to having the above function is controlling administrative costs (i.e. not dealing with insurance billing).
3) Patients need to know where the money they (or their employers) pay in insurance premiums goes. I believe if this information were readily available, cash practices would grow and a market could develop for plans that cover expensive events (hospitalizations, surgeries etc.) with low administrative costs, modest executive compensation and thus lower premiums. This might or might not require regulation to accomplish.
If (hypothetically) a patient, union or business has a choice between a premium of $300/month and $60 for a 15 minute visit vs. $1000 premium and $40-50 "copay" ,many might want the former. The overall expenditures --on a societal level--would be lower and the physician would make more money and have fewer headaches.
4) Something needs to be in place to cover the kind of care almost no one can afford on their own. People with low incomes could receive subsidies to join the market or be cared for in clinics staffed by salaried physicians. Loan forgiveness or scholarship programs could be offered to draw young physicians to work in such clinics.
5) HSAs could be available to encourage preventive care and help people with chronic conditions afford office visits over the year.
6) With lower administrative costs and not needing to cover routine office visits, perhaps compensation for surgeries etc could be adequate.
Doctors have tasted the easy money of Insurance but now like Dr Faustus we have the reckoning.
How uplifting! Common sense and intelligence exist in American medicine without ANY government or corporate involvement!
Bravo!
a tier is always more aptly defined by each patient who brings their own set of values/biases/misjudgments of what they perceive as adequate care...
the uneven unfair care fear of a multitiered system is not germaine nor evident...
what is unfair and uneven in this land of 3+ million of the most heavily insured is the lack of prim care internists to see to have any care at all...
our current health insurance and medicare system of price fixing OUR VALUE below market levels x 25+ yrs has dried up the MD resource permanently!!!....now that's a moral quandry worthy of national debate...
the real question for Americans is not about the uninsured and access BUT that the insured will most certainly be undoctored and have access to nothing!!!
Most of this does not apply to me or other Emergency Department physicians.
If patient's exercised, ate properly and avoided tobacco, and substance abuse the cost for health care coverage would dramaticaly decrease; and those who chose to ignore their personal health responsibilities should be charged a premium for coverage.
If physicians stopped participating with low reimbursing insurers, then we could all start to enjoy the benefits of a market driven health care system and physicians could control the quality of health care delivery.
If the politicians would face the facts and address the real problems, not use this as an oportunity to push a leftist agenda, then we would see tort reform and insurance competition.
The facts are that none of this is likely to happen. Yes, everyone will complain about new regulations and decreasing reimbursement and even threaten "to go cash only", but if that were true, then why continue participating with insurers who have imposed draconian, unfair and sometimes illegal measures to further tighten our cash flow, for years on end. The fact is insurers don't respect us, politicians (lawyers) don't respect us and now we are about to lose what little respect we have left from the only group that realy matters, our patients.
I really hope I am wrong. I hope we finally do stand up for what is right. Our right and duty to exercise the privilege to care for those in need. This is what it is and has always been about. No, we don't need goverment telling us how to practice. We don't need insurers telling us how to practice and we don't need lawyers preying upon our patients like vultures in the Kalahari. I can try to educate my patients to the benefits of investing in their health through exercise, proper diet and tobacco abstinence. I can waste my energy and money trying to influence a corrupt political and legal system that has latched onto our health system as the goose that lays the golden egg. And most importantly I can retain my self respect and my ability to practice as I see fit by saying NO TO PARTICIPATION.
It is very clear to me that COP is the way to go for doctors and for pt.
Return healthcare to free market if you want to save this country.
There is no such thing as free lunch.
If govt offers that, someone is paying for it in some way.
Entitlement burden coming from govt takeover of healthcare will sink US.
A truly revolutionary idea...seems to work for almost all other businesses in America.
I have had similar experiences to the doctor who said his value to his patient was $10 dollars for the co pay, this is a routine occurrence.
Instead of "cash only", we should consider barter only, when the cash has no value.
Thanks for listening.
By no means am I busy enough to look at this as my sole income, so I also do locum tenems part-time. But my house-calls practice is what I truely love. And I do find that parents are willing to pay me for my time, and they're grateful to have access to a physician willing to answer their questions. Personally, I find the patient-doctor relationship much more emotionally gratifying doing this, than any other practice venue I've been in.
I'll keep doing this as long as I can keep making my malpractice, and I suspect that when I hit the 5 year mark I'll be able to cut back on the locum tenems.
Just my 0.02 cents....
Oh, that's right, the government and the insurance companies would lose CONTROL . . .
Yesterday, I got an EOB from a patient appointment in December 2008. It was a joke. I can't believe I put up with that kind of crap for those years....low reimbursement, insurance discount, waiting 9 months to get paid. Forget that. I'd rather work at Starbucks than go back to an insurance practice.
No one needs health insurance for office visits. Think of it like car insurance. Who expects their car insurance to cover oil changes and gasoline? It's ludicrous.
I am a psychiatrist, so it is quite easy, as I charge based on my time and complexity.
I also charge for phone calls that are more than brief answers to simple questions.
I charge for forms, letters, reports, etc.
Can you imagine going to the grocery store, loading up your cart, then at the check-out counter telling the cashier to bill your "food insurance"? Can you imagine asking how much the lettuce costs and being told, "Well, that depends on your insurance and whether we have a preferred rate." Imagine asking how much you owe and being told, "Don't worry - just pay $15 now and we'll send you a bill at the end of the month after we see what we collect from insurance."
Isn't food a basic human right? Water? We are expected to pay for those things every month based on our utilization. Why is medical care different?
It's different because we, as physicians, went along with this ridiculous system for over 50 years because we were being reimbursed in ridiculous amounts, basically charging whatever we wanted because insurance paid a certain percentage - without asking questions.
We need to get back to a system that involves the patient feeling the cost. There is nothing unethical about that. Any third party between the patient and the physician - whether an insurance company or the government - screws things up.
The only disadvantage may be the guilt feelings of not being able to accept all patients and not being able to care for everyone. I have solved this solution by now volunteering in a free clinic several days monthly. With my new schedule, I am able to volunteer and teach medical students, activities I had to drop as I became busier in my old practice.
www.Sermo Doc 74.com
I see for everyone what we have done in our practice the last few years...
Refuse Medicaid (except emergently, family members of long established patients and colleagues).
Become NONPAR on Medicare and collect EM services up front (bill after a deposit for procedures) until the time that the Medicare limiting charge does not cover costs (next year if it is not fixed), then opt out of Medicare at any quarter that it fails (which screws the eneficiary unfortunately).
Leave bad payor contracts. We even left Blue Cross. It wasn't simple or easy but has gotten us exactly what we needed...adequate reimbursement. Moreover, we have had other networks now come to use with much better offers up to 150% of Medicare.
Filing a claim electronically is not a really big deal. This is simple. Most EMRs and practice management systems do it at very low overhead. It is trying to collect balances which raises overhead. Giving a discount for paying at time of service is the key to collecting up front.
When patients are paying for services they receive the market will respond with cheaper MRI scans, shorter waits in doctor's offices, ?ultrasound booths at the mall?--- hell I can get my teeth whitened there!
The same system brought 1980 $3000 VCRs down to 2009 $29 DVD players,etc...... there are countless examples.
All socialist systems end by collapsing, leaving their dependents destitute. Move to cash now.
Who is John Galt......................................
I don't think there's any legal way for the government to stop this transition. The worse they make third-party interactions, the faster it will happen.
Patient education is the key. DON'T call it concierge practice, everyone thinks they can't afford it. DO shout loudly about the $XX / month direct debit from the checking account.
Providing patients with MSAs that were pre-funded by their employers or the feds (for low income) would cut the whining about the costs of labs.
The best 'spending plan' for patient responsibility:
MSA with 2 grand from employer (annual but employee doesn't own), 2 grand from employee (can accumulate, employee owns), then 'overage' or 'catastrophic' insurance kicks in. Lots of competition in the design and pricing of these plans.
At a meeting earlier this week, Erika Bliss MD from Qliance presented data on the cost of dealing with insurance in a typical primary care office. According to the study in Health Affairs, the national cost is $31B/yr, average of about $68,000 per doc per year. The costs increase in primary care. Each claim submission comes with fixed costs. The smaller the claim amount, the greater the percent of the claim eaten up by the fixed costs. In Dr. Bliss' calculation, primary care loses about 40% of payment to the costs of billing.
This cost analysis does not account for the extra costs of dealing with prior authorizations and other administrative trivia.
Primary care practices that have moved to the direct practice model (aka 'cash practice') have gotten off the hamster wheel, can spend the time they need to deliver on their full professional obligations. I don't mean to say that this delivery is ubiquitous in or exclusive to direct practice, just that I see these practices as finally having finances aligned with the work of being a good and effective physician.
Some salaried systems approach this level of simplicity and elegance, but now we have options beyond 'salaried' to achieve professional and ethical alignment with our patient's best interest.
Until there are sensible, rational, and ethical policies that truly support good care for our patients, we can look to direct practice as a setting where the possibility exists to close that gap right now.
I know this isn't the total solution, but our system isn't that broken. Our government run option (Medicaid/care) is poorly managed, and the oppressive restrictions force insurance to work harder for profit. I love Atlas Shrugged, and I really feel like the book becoming reality..........
Why hasn't anyone cornered Obama and said, "please explain to us why health care costs so much?"
Will move for Freedom!!!
a person(the pateint) gets instant credit(Health ins billing) by just walking in without any financial assessment.
It would be fantastic to have a fee for service-cash only practice . The patients
don't seem to understand that billing their insurance co is a service that
we are providing and not a patient "RIGHT". If you are a unique specialty
in demand without much competition in the area you may be able to test the
Cash only practice ,otherwise patients will leave if they have to pay more than their
copay.
If a patient can't afford my full fee, I'll reduce it to something they can afford, and I can afford to accept. If we can't reach an agreement, I'll refer them somewhere else, and I won't charge for the initial consultation. But that rarely happens.
Because my husband is also self-employed, we have no reduced rate on insurance, so we have only catastrophic insurance, and we pay for our medical care out-of-pocket. It costs us less than it would to have full coverage, even last year, when my son had knee surgery. And we don't run to see a doctor for every little thing.
It's totally workable this way. Couple this system with Health Savings Accounts that let you carry over from year to year, set up efficient clinics for people who really can't afford treatment, and you don't need crazy universal coverage.
Using medical insurance to cover every little office visit is like using auto-insurance to pay for gas. It makes no sense.
There is already a blue print for govt health care.That is Public Health Service,Military medicine and VA.Just extend the PHS to general public.No need for filing.Doctors and paramedical personnel are salaried with benefits.Those who wish to have their own practice can still do so.That way public has a choice.Just like public schools vs private schools.It will solve the access problem but the quality of health care will be whole different problem-
The incentive structure of medicine that offers a premium for procedures encouraged doctors to practice specialty medicine, but it cost them their ability to understand how to do prevention, for themselves or their patients. However, these are the doctors society is listening to about everything, but they can only offer us rescue care. They started telling generalists what to do and how to practice, but they can't see that what they offer is a fragmented perspective that presumes that patients have only what they treat. It took me years to figure out that I could not follow the recommendations of specialists for prevention, only for rescue. They cannot see that my patients have multiple problems that require a comprehensive solution to all of their problems simultaneously, specialists could only offer me "parts" advice. The problem with medicine is the medicine we practice. We can't even see simple solutions to patients problems. Gastroenterologist think that it is ok to continuously suppress peoples stomach acid, for example. They are completely unaware that they cause patients neurological problems when they do, since patients don't return to them with the problem they don't see the problems they cause. It is inconceivable to neurologists that patient's dementia can be caused by problems in their stomach. There is no working model in medicine that even acknowledges people's parts interconnect. Doctors are victims to their own inability to see the big picture and suffer from all of the same diseases as their patients while taking all of the same drugs and having all of the same procedures. Patients just hop from doctor to doctor getting another drug with new side effects. The plan for everyone in insurance (patients and doctors) is to die on 20 drugs. Some doctors have long since figured this out. I have began a grassroots campaign to explain to patients just what they are getting from the insurance market, rescue care and nothing more. I do not rely on my insurance company to keep me healthy because they have not a clue how to do so. All smart patients are willing to pay out of pocket because they know that all conventional medicine has to offer them is more and more drugs, and doctors simply have been brainwashed by training to do nothing else. Its not their fault, but is true that if a non-surgeon doesn't have a drug for a patient, they don't have anything else for them. I do not want to dismantle the rescue care we have, but doctors themselves can expect to get all of what they see in their patients until they realize they have been punk'd by big pharma, they own you.
When has insurance even given us anything but restoration from catastrophes anyway? Car insurance doesn't provide maintenance, neither does homeowners, and we know somebody has to die to collect on life insurance. Why do we think that health insurance offers people anything different? It doesn't its just an illusion. Medicine is priced out of range for most people to access without insurance, so people think that when they use insurance that they are getting prevention. They are not, its just rescue care just like other forms of insurance. Some of us have figured it out, most people still have not. Many doctors who are running cash practices practice fundamentally differently (not just the concierge practices, they are just organizers for a fee). Some of us actually returned to the use of basic science, that most doctors abandoned, in lieu of prescribing drugs, which is why they don't understand the cause of anything.
1. How do you deal with referrals? If a patient has BCBS/Aetna etc.and they need an MRI, specialist referral etc. how does that work? If you are not in network you can't.
2. Meds - I am constantly pummeled by the fax from the Ins. Co/Medco about formularies etc. Do you just tell the patient "deal with it" change it use only generics?
3. I still go to the hospital. Do you simply charge the patient for this or do you have to stop going to the hospital?
I am sorry it sounds like I am trying to get a free consult on DIY cash-only practice. I would just like to know.
I've known a couple of psychiatrists who had comfortable cash-only practices. It seems to work fine for them since patients who finally admit to themselves they need psychiatric care understand it's going to take several (or more than several) visits to rewire their fray of emotions and thoughts. They also may have the insight that the doctor may not be able to fix everything.
In contrast, the FP is expected to fix whatever problem (or multiple unrelated problems) the patients wants addressed. The resentment when we can't may manifest as unwillingness to pay. It would be nice if those in primary care could share specific details of how they have been successful.
If 'Public Option' plan is enacted based on Medicare fee schedule, I would guess 1/3 of anesthesiologists would retire within the next few years, and NO medical students would consider it a viable specialty.
The second prediction is that with essentially all the people in your practice being Medicare patients, they will have to compel doctors to see them. Doctors ("specialists" especially) won't be able to just dump them back on the primary care docs anymore. This will result in a mass exodus from the business. Broke primary care docs will get jobs as a manager at Applebees (and make more money) The fat cats will just retire--they aren't going to do primary care work or work for primary care wages. Who's going to see all these people???
Thirdly, critics like to talk about the government interfering with the doctor patient relationship. Have any of you folks spent any time refilling prescriptions lately?? The private sector insurance companies have been telling you what you can and cannot prescribe for decades!! Drug reps don't even talk about efficacy of their products any more. They talk about which insurances cover the stupid stuff. Why should we give a crap about what is Tier 1 or tier 2...??? Does it not matter whether the stuff works?? The government did not invent the concept of "prior authorization." Anybody old enough to remember when all you needed was a doctor's order to get stuff done?? WHEN the government takes over, it will be time for many of us to find another way to make a living but hopefully those of you who will still be seeing patients will convince your politician friends who take all your republicam money to make sure more stuff gets covered
I'm not so sure that's a safe assumption.
Let's say my neighbor smokes like a chimney, drinks like a fish, and eats like a pig. At, say, 55, he is fat, emphysematous, and cirrhotic. After two years of progressive worsening of the above, he dies.
I don't drink, don't smoke, and exercise faithfully. At age 70 my yearly PSA shows a rise. My early prostate cancer is cured by resection. At age 75 my annual labs show high lipids. The statin causes rhabdomyolysis, so we finesse that. At 78 my interval colonoscopy shows polyps, which are resected. At 80 my annual physical shows new adenopathy, which proves to be low grade lymphoma. R-CHOP obtains an apparent complete remission, but let's not kid ourselves, that isn't cured. At 82 the lipids catch up with me, I have a STEMI (despite my having legs like Jim Fixx and pecs like Jeff Life). I get stented and am almost as good as new...
By this time my medical care has cost more than my neer-do-well neighbor's. Now, I've lived much longer. than he did. Maybe my general good health has been more enjoyable than a self-indulgent booze-, nicotine-, and fat-fueled haze. But unless I am polite enough to just drop dead with my first illness, my various preventative triumphs will not cost less, they will cost more.
I enjoy taking care of the over 65 crowd...generally less whiny than younger folks and actually have problems I can apply my skills to and make me think. I feel like I am providing a real service to the younger folks on medicare since they are by definition disabled and chronically ill.
Oh yah! I appreciate that those 20 and 30 somethings that pay well and take 5 minutes...allows me to catch up and make some real money. But as far as pure doctoring goes, give me the medicare crowd any day. I'll either get my reward in heaven or get a huge financial windfall when the rest of you have dropped medicare and the feds respond to the crisis by dramaticallly increasing reimbursement.
barbaric is a strong word. Should docs lose or pay their own money to treat patient's whose insurance puts them at a loss. That is either called bad business or charity.
I'll bet a good number of docs would compete for seniors care if allowed to get paid at time of service, without the bureaucracy. And all medicare would need to do is 2 things.
1) reimburse patients who choose to see a opt-out physician.
2) make it a law that all physicians need to post their fees in a transparent way to increase competition.
as for the feds increasing "reimbursement" in the future to levels that allow docs to not lose money, I say , "what are you smoking?"
1) reimburse patients who choose to see a opt-out physician.
2) make it a law that all physicians need to post their fees in a transparent way to increase competition.
These are brilliant ideas.
It will also reduce administrative burden (and cost) on medicare intermediaries and CMS can save money.
1. How do you deal with referrals? If a patient has BCBS/Aetna etc.and they need an MRI, specialist referral etc. how does that work?
when you are not in network, you are not required to do this crap. Seriously. Yes .It was discussed a while back on sermo.
2. Meds - I am constantly pummeled by the fax from the Ins. Co/Medco about formularies etc. Do you just tell the patient "deal with it" change it use only generics?
You do it as a favor to pt. It is upto you how you want to relate to them. there are several ways out - asking pt to fill, charging for filling them, charging PBM for filling or simply refusing to do it. But, remember, these options save money to pt and many times they are forced to use them... so you dont want to tell them to forget about it... you will lose pt.
In practice, my approach is to encourage use of Walmart 10$ for 3 month plan. I dont contract with crappy insurance and no medicare advantage plan, so my PBM fax burden is quite small. Also, I have their number blocked so they can not fax it, they have to mail it and so I do not get one copy of the same Q24 hr.
3. I still go to the hospital. Do you simply charge the patient for this or do you have to stop going to the hospital?
Whether Hosp work makes sense for your practice or not is a separate qn and you might want to address that before you try to face qn of charging pt.
Quite likely, you will find that Hosp work is a money losing venture for you anyway. Will you lose pt if you dont do Hosp work? I dont.
After careful analysis, I devised a crude formula:
If your average inpt census of paying inpt is more than
Minutes required to reach from office to nearest medical floor/3
you will profit by doing inpt. (as much as or more than what you make in office) .......... if you are not busy in office, its different.
I am sorry it sounds like I am trying to get a free consult on DIY cash-only practice.
sermo is made for it only.
Dont hesitate.
If we can get out of debt, would love cash only.
we see our own hospitalized patients, and don't know how that would work. Need to speak with others who are doing this.
All Doctors should "JUST SAY NO to Managed Care" and get off all the plans and go back to the fee for service method and get reimbursed for our hard work...not just pennies on the dollar.
But physicians are too scared to resign from their manage care contracts as they are afraid that their competition will not follow suit and they will lose their patients, etc.
So, until all docs stop participating in manage care, we are screwed.
Fee for service is the answer...not cash pay.
A GP office visit circa 1966 was $7.50. Penicillin shot, $1.00. Basic laceration repair, $ 25.00. Patients expected to pay. If they couldn't afford it, cut the fee or do it no charge. Those good days could come again if we could all stand together and make it happen.
so as long as some specialists remain on insurance plans, I don't forsee it catching on so soon, unless you practice in a rural area or area with very few specialists.
Baucus Bill Amendment removes HSA's.
Eliminate or table the Baucus Bill, BO's Bills and all other Socialist Government Bills..
Pass a Bill for HSA's with tax deductions, free choice, no government control, and Docs can charge/bill Patient directly like Dentists. Patients could pay from their HSA directly with a Debit Card or similar mechanism. The Patient (and his HSA) would complete the insurance/government forms for reimbursement.
No Government control of Doctors or their Practice.
Freedommmmmmmmmmmmmmmmm....................................!!!!!!
Thanks
There is absolutely nothing wrong with getting paid for your work. And you are correct...something is very wrong with this picture.
If anyone else purchased services/goods from a business and didn't pay, they'd be either arrested or referred to a collection agency. But Big Insurance gets away with robbery. It's looting from the system, and ultimately hurts patients access to affordable health care.
That's why unfortunately, physicians need to switch to a cash only model, and let patients realize what the greedy insurance companies are doing behind the scenes, and hopefully revolt. It is the only way physician groups will be able to fiscally survive in these dire economic circumstances which are worsening everyday.
Monday, September 28, 2009
By Richard R. Kelley
I've been listening carefully as President Obama has been defending his health care reform ideas. Although his goal of ensuring access to health care for all Americans is something no decent person could disagree with, I believe the bills that he and the congressional leadership are pushing are deeply flawed, conflict with the best interests of all Americans, and in some ways violate the values all physicians take an oath to uphold.
(continued...see link)
See link for rest of article by Dr. Kelley on Health Reform.
www.denverpost.com
Richard R. Kelley, M.D., is chairman of the Colorado Neurological Institute and chairman of Outrigger Enterprises Group, a hotel development and management company - the nation's 12th largest - that operates in Hawaii and the Asia-Pacific region. EDITOR'S NOTE: This is an online-only column and has not been edited.
A 'public option' aka expansion of Medicare to all age groups is on the horizon.
Then shall come the word from on high-
Yes, state by state the legislation will be passed-
"If you want a license to practice medicine in this state, you must accept public insurance."
The government will thereby take the cash-only practice off. of. the. table.
Quality of Life left in the free practice of Medicine, so it shall die quietly; "Not with a Bang but a Whimper" (TS Eliot-The Hollow Men).
We are the hollow men
We are the stuffed men
Leaning together
Headpiece filled with straw. Alas!
Our dried voices, when
We whisper together
Are quiet and meaningless
As wind in dry grass
Or rats' feet over broken glass
In our dry cellar.
www.artofeurope.com
Liberty or Death...the latter is here!
as above I cannot go cash only because the other specialists in the area will still accept insurance. People really don't care about access, they will wait so their visit is covered. 8 years in and regretting every day of it.
I present this take to anyone considering medicine as a career: "It is the same as being president, if you are really smart enough for the job why would you run."
Instead of taking employer-provided health care insurance, as is done now, individuals could ask employers to give them the same amount of money the employers now spend on their insurance coverage. This would not be cash in hand, but money deposited into each individual's Health Savings Account.
Like the health benefits insurance employees now receive, this money would be tax-free. It could be spent only for health care - say with a debit card that taps into the tax-free Health Savings Account. People would use this money for ordinary expenses - visits to the doctor, immunizations, routine tests, most prescriptions, and so on. Docs would bill the Patient, no one else. Bill the Patient and collect now; the Patient pays from his HSA with a debit card and then he deals with the Govt., Insurance Co., or whoever, not the Doc!
What about big expenses, like a stay in the hospital or a CAT scan ? The Health Savings Account probably couldn't cover those.
But it could cover the low cost of a high-deductible catastrophic insurance plan, which would kick in whenever you incur a large medical expense.
For most people, these events don't occur very often, which is why such coverage is affordable.
The higher the deductible, the cheaper the insurance policy - just like auto insurance. If you want a plan with a low deductible that covers routine medical expenses, you'd pay a lot more.
But that would be the Patient's decision, not a government bureaucrat's decision.
The Senate has an Amendment to remove HSA's...wonder why? Perhaps because the HSA would remove Health Care from Government control?!
So I'm entertaining buying an EMR when I'm done and going cash only. This isn't because of the healthcare reform, but because I got into medicine and have 200K worth of debt because I like making kids feel better and teaching adults and children to take care of themselves.
I'm catching flack about this from some of my more idealist colleagues, but having someone dictate to me what I can and cannot do is infuriating. We'll see what happens...
www.kevinmd.com
do fee for service for annuals/problem visits, etc. Have a certain amount of practice money devoted to "indigent care" (ie people who can't even afford basic flat fees that wouldnt cover the price of the test/labs, etc)
Do 10-15 deliveries a month (I usually do 30-40) where I could guarantee my prescence at a delivery, 1 hour long prenatal care visits and monthly classes on nutrition, exercise, childbirth education, etc. For these women, would charge flat rate of $5000. This fee would be "global" and include all visits, classes, pager access, etc. The patient would use their insurance for the actual hospitilzation...
Have a small office (or share) with another physician. No coder/biller, one front office person and one MA.
I know, it sounds like i'm smoking crack.....oh well, just a thought
"Can I get off of this ride soon? I'm feeling sick".....
Some choices are:
An Amendment to provide Universal HSA's for Patients.
Opt out of Govt. Programs and Insurance.
Quit and find another career.
Suffer on till burn-out comes.
Sermo Doc 122: LOVE that saying...the "grass" in this country has been taking a beating for quite a while now.... :)
TIPP: Totally Informed Private Practioner (or cash for the waiter; inside information??).
As an ED doc, I'm a bit stuck but you CAN ask for payment, once you've treated them. We have done that in the past and will likely do it again soon. For most uninsured, it is the ONLY payment we'll get.
I agree that Medicaid pts take advantage of the system because they don't have any co-pay at all. So why not go down to the local ED to ask them about that bump I've had on my leg for 3 months. Don't cost nothin'!
I have no problem taking care of the working poor that have no insurance, who pay me whatever they are able. Most are truly grateful and I got into medicine to help people, after all. However, I am tired of having to practice defensive medicine so I don't get sued after being FORCED to take care of some of these people. You should not be able to sue any doctor that takes care of you during a true emergent situation. Ever notice all of the lawyers on TV offering to "get you your money if you've been hurt..." It's not all there is to the problem but tort reform needs to be part of the equation.
My theoretical monthly Social Security check will just cover my student loan expense... if SS goes down, too bad so sad on collecting my student loans when I'm older....
Dr. Frank: The solution to your problem would have been to obtain a retainer up front, or charge a yearly fee that included email and phone consultation.
If a patient believes that the care a physician provides is important and improves his quality of life, his functioning and his ability to deal better with the world, he should then be expected to pay for what he gets. Accusing doctors of charging 'too much' for the life-saving help they provide, is worse than going into an expensive, upscale restaurant, consuming a sumptuous meal and then demanding to pay only what it costs to buy an extra-value meal at McDonalds, simply because the person 'needed' the food.
One person's need is not a valid claim on another's effort.
I am also concerend that another blank check will be handed to the consumers of health care and the party that will bear the logistical and legal burden of gatekeeper and rationer of care will be the docs.
IOU's for Doctors and Health Care Providers.
Good only at Wal-Mart for 30 days!
IBD stands for Investor Business Daily, a newspaper similar in many ways to the Wall St. Journal. It conducts polls, similar to those done by WSJ, ABC, NBC, etc.
I have tried for several minutes online and am embarrassed to admit I cannot determine what TIPP stands for.
IBD/TIPP Doctors Poll Is Not Trustworthy
by Nate Silver @ 11:58 AM, 9.16.2009
Share This ContentI'm flying 35,000 feet somewhere over Eastern Ohio now -- isn't technology wonderful? -- so I can only comment on this briefly, but the Investors' Business Daily poll purporting to show widespread opposition to health care reform among doctors is simply not credible. There are five reasons why:
1. The survey was conducted by mail, which is unusual. The only other mail-based poll that I'm aware of is that conducted by the Columbus Dispatch, which was associated with an average error of about 7 percentage points -- the highest of any pollster that we tested.
2. At least one of the questions is blatantly biased: "Do you believe the government can cover 47 million more people and it will cost less money and th quality of care will be better?". Holy run-on-sentence, Batman? A pollster who asks a question like this one is not intending to be objective.
3. As we learned during the Presidntial campaign -- when, among other things, they had John McCain winning the youth vote 74-22 -- the IBD/TIPP polling operation has literally no idea what they're doing. I mean, literally none. For example, I don't trust IBD/TIPP to have competently selected anything resembling a random panel, which is harder to do than you'd think.
4. They say, somewhat ambiguously: "Responses are still coming in." This is also highly unorthodox. Professional pollsters generally do not report results before the survey period is compete.
5. There is virtually no disclosure about methodology. For example, IBD doesn't bother to define the term "practicing physician", which could mean almost anything. Nor do they explain how their randomization procedure worked, provide the entire question battery, or anything like that.
My advice would be to completely ignore this poll. There are pollsters out there that have an agenda but are highly competent, and there are pollsters that are nonpartisan but not particularly skilled. Rarely, however, do you find the whole package: that special pollster which is both biased and inept. IBD/TIPP is one of the few exceptions.
...see also methodology, pollsters
www.fivethirtyeight.com
great news today in for emergency Dental surgery today... Snow birds to TEXAS are saying you can ONLY get DOCS who are CASH ONLY !!!! GO TEXAS and SAVE THE UNION from Communism!! the biggest joke with current health care reform is to TAX those who HAVE DECENT health care to pay for those who do NOT!! Erode the health of those working with Insurance to "help" those who , here , anyway , REFUSE to go to where there are JOBS!!..
I know several psychiatrists, mostly younger and from backgrounds that allow them to gradually build their practices, who are building cash-only practices in my region. This is all well and good, but I fear it does little to deliver care to those who need it most.
As more and more physicians refuse all insurance payments and accept cash only, competition among this growing supply of physicians will lead to lowering the price of an office visit.
YET without us, the insurance companies have no service to offer. If enough of us said NO to insurances, we could ALL go back to fee for service.
I'm all for SOME type of reform, I just haven't seen anything that I think really could or would help. It's the infamous Catch 22.
Has anyone here actually tried SimpleCare.com?
Friday October 2, 2009
Welcome to SimpleCare.com, home of one the largest patient/doctor organizations in America. Here you'll find a host of resources, links and contacts that will help you take control of your healthcare situation. If you're a patient looking to cut your healthcare costs but get better care, SimpleCare is for you. If you're a doctor looking to practice medicine your way while also getting fair market value for your services, SimpleCare is for you too. And if you're a business owner struggling to insure your workers, SimpleCare has what you need. Better care for less money - it's just that simple!
How does it work? We call it PIFATOS - Pay In Full At Time Of Service - and it is truly a "Cash-Based Revolution." A patient sees a doctor for a non-catastrophic reason - yearly check-up, a nagging flu, a twisted wrist, an aching stomach, etc. The doctor bills the patient after the visit. The patient pays in full before leaving. Because doctor charges are anywhere from 25 - 50% inflated due to administrative costs caused by the health insurance industry, you'll be paying drastically reduced rates for your medical expenses. In conjunction with a regular catastrophic health insurance policy to cover extremely costly procedures, PIFATOS can save the average healthy adult and/or family up to $5000/year!*
Now, ask yourself. How often do you go to the doctor? And when you do, how long does it take the doctor to treat what you have? The fact is, most healthy Americans don't visit the doctor all that often for non-catastrophic reasons, and when they do, they don't visit with the doctor for all that long and they don't receive very elaborate treatment. So why are most healthy Americans paying huge sums of money to insure themselves against regular doctor visits that actually aren't that expensive? They shouldn't be, and with SimpleCare, they don't.
I believe SimpleCare is THE most powerful solution to the problems plaguing America's healthcare services, and I trust you'll believe so too once you browse through our site. If you have any questions, feel free to contact me. Together, we are changing the way America stays healthy!
To Health and Wellness!
Vern S. Cherewatenko, MD, MEd
Founder & CEO, AAPP/SimpleCare
If things get rough, the best solution for us would be cash only for most diagnoses and accept Medicare/Medicaid for that group noted above. I would even consider cash only for most patients and charity care for this group.
I hope that I am not forced to give up care of our most needy patients in order to run a viable practice.
I grew up in a democratic household, and if your not democratic when your 18, you don't have a heart, but if your still democratic when your 40, your stupid. My democratic friends always want to save the world ,but with someone else's money. Let's implement catastrophic plans for hospitalization and real emergency room visits and start health savings accounts for outpatient services. We then can get out of the insurance business and get competitive in the doctoring business. We also need to get some serious tort reforms. When our overheads are low, and we don't have to run patients through like cattle and we can afford to have our own practices and not be bought, and bound and gagged by hospitals buying our practices, maybe just maybe we will not be mad at every patient that comes in with a 8x10 list of problems and will set the price according to what we do for them and not some false 99213 code, but maybe a flat fee for 3 or less problems, and have menus with real prices, so the consumer will know what things cost. Competition will drive down prices and people can cross state lines to ge the care they want. I had a cash only practice 3 years ago, and it doesn't work for two reasons1. 80% or more people have some kind of insurance , they don't know a damn thing about it (such as deductibles, prevention coverage, copays, etc.),but they want to use it, and then they scream when they get a 200,00 bill because you have to bill them after it goes through insurance and 2. the persons that did show up to this beautiful cash pay clinic never had the 45.00 to be seen and stiffed me. I had to go back to insurance. It doesn't work unless your in a predominant hispanic or amish area and have this population that also like cash pay. Insurances are killing the doctors. One thing I will mention is that the book by Ayn Rand-Why Businessmen Need Philosophy will open your eyes to what is taking place in this country as we speak and I for one am not going to sit on the sidelines any longer. One of my partners is a State Rep and is going to run for the Senate- he has a good heart and is a very good patient advocate. We need to go back to having charities and us being a part of those for people who cannot afford anything. Also, I can't be expected as a family doc to charge 45.00 OV when my GI, buddy charged one of my patients 800.00 for a 5 min. no hands on pre-colonoscopy visit. What is that? Pathetic. I've went on enough, but lots of good people have made comments and most are very interesting. Good luck everyone. Dr. Deb
See link for op/ed by Dr. Kelley on Health Reform including HSA's.
www.denverpost.com
Richard R. Kelley, M.D., is chairman of the Colorado Neurological Institute.
Obviously, I wasn't in excrutiating pain (more worried about some other pathology, with the discomfort and microhematuria), so I called about 5 imaging centers. Talked to their office managers. (No, I didn't tell them I was a doctor). Found the cheapest ones, and then called all of them AGAIN and negotiated. Finally asked the last one "OK, what if I bring $20 bills?" and got another 10% off.
Ended up being 20% less than what my insurance would have reimbursed.
Is there someone out there who'd like to form a private doctor owned, non-profit company to negotiate or barter these services (like the really old days), i.e., "BarterbyDocs.com", "DocsforYou.com", or "LowcostDocs.com"? I'm sure you all have better names for such a service but there are companies out there that already provide this kind of service like:
Medical Cost Advocate (MCA):
Medical Cost Advocate provides health care cost reduction solutions to benefit consumers. Medical Cost Advocate is the expert source to validate billing accuracy, negotiate medical bills and regain control over your health care costs. We can reduce your medical bills after services are performed or reduce your procedure price before services are performed.
www.medicalcostadvocate.com
Just thinking??
If only 10% of my current patients give me $1000 each at beginning of each year, I could do everything I do for them now--checkups , visits, minor in-office surgeries, even "give away" the lab work, and just tack on exact cost of high ticket items like vaccines, as a convenience. Huge reduction in overhead, including staff. I'd be making two times what I get to keep now, but would have less than 8 visits per day, have more time to myself, wouldn't have to deal w insurers. Patients would need to keep Major Med for catastrophic care, and high deductible (set aside what they'd save on too high premiums for the ppo/hmo ins they've got now into HSA's)
BUT, if we all did this, who'd take care of the other 90% of our patients?
Reguardless of the maner in which "reform" occurs, if "THEY" don't compensate doctors fairly, ie: stop medicare paycuts, fix flawed MC formula, (all insu links to medicare as a percent one way or the other) allow for increase in compensaton to keep up with increase in the true costs of running office--or I may be crazy enough to go cash only, and so may a lot of other PCP's.
I just received a mailing from a Doctor in my area doing exactly as you outlined. He's trying to recruit new patients but I don't know what success he's had or how much he's charging per capita.
I also know of several other Docs in State who are doing the same thing.
If nothing is done by Congress to reform the current system without gov't. control, then it will be survival mode for those who want to stay in Medicine!
Good luck to us all.
There are some serious civil liberties issues there. Hopefully our profession will strongly fight such efforts through appropriate legal means.
We should just tell our patients, "if you want your insurance to reimburse you, then send them the bill with a request for reimbursement." Of course, initially, none of them will be reimbursed. But as more patients demand insurance that reimburses our de-bullshitted bills, then insurance companies (and maybe even ultimately Medicare, who knows?) will respond with insurance products that make sense.
In the meantime, WE WILL BE FREE from all the ridiculous interference we've only tolerated this long because it was inflicted on us in such a gradual, insidious manner.
Dan Jones, MD
www.jonesplan.blogspot.com
www.cms.hhs.gov