Thank you once again, Dan, for showing the foresight and leadership that is so necessary in our current environment. I'm looking forward to this effort.
This is another "leveraging of collective intelligence"-based idea. An interactive map of where cash-only practices have proven feasible prior to whatever federal legislation that is enacted would be useful.
We all work now for 45-50% of charges thanks to Blue Cross and other 3rd party payers. It's about time that we explore normal business operations with discounts per physician choice based on the economic status of our individual patients. The Sermo and AAPS organizations provide us with a good population of MD's from every state from which to "organize and share information" about cash only practice. Great idea now let's get to work!!-----TOGETHER.
Let us not forget that many third party contracts are ties to a percentage of Medicare rates.
When the Medicare rates drop 20%, so do all your other contracts tied to Medicare.
So if say that is a 15% drop in revenues, but the same 5-10% increase in expenses....
and with an overhead of 60% for a FP.....
that leaves 40% premedicare cut for takehome pay...
1) Join a big group that has leverage to negotiate
2) Work as an employeed physician
3) Drop third party contracts now, and become a doctor who first and foremost cares for patient's at whatever reasonable and amrketbl fee you decide... You can also waive fees to the needy without worrying about getting sued by the government!!!
The current health care system has been exhaustively discussed with my patients on a daily basis. The patient consensus is TRUST and CONFIDENCE in the doctor patient relationship with emphasis on AFFORDABLE patient responsibility vs government centered health care rationing. In ALL of these patient population, the doctor confidence-trust relationship supersedes their financial obligations and they are more than willing to pay their personal financial responsibilities.
Summarily, these pateints are willing to pay CASH ONLY basis! For hospital and emergency visits, a catastrophic insurance would be most acceptable!
Their awareness of the current system has matured to patient NEGLECT and UNDERSTAND (un)SGR which they attribute to MISTRUST in governmental politics and mishandling the current economy. Along with their in-bed relationship with the third party system and their vested financial interests ANY private inusrance /public option proposals will be MET by patient doctor disgust, skepticisnm and as had been predicted will never succeed!
ANY PME recommended by the SERMO docs are undoubtedly supported by these patients who had put their TRUST-CONFIDENCE in their choice of doctors and entrusting their health care!
The continuous dialogue between the dr/pt relationship is NO SUBSTITUTE to a genuine health care and undoubtedly remains as the key to a successful health care delivery system!
All other current proposals/reforms in the health care industry will REDOUND to POLITICS as USUAL regardless of party color and the current economic crises may ignite a people upheaval as displayed in all of this town meetings and online responses !!
Let me redo the math in case I screwed up earlier.
For a small family practice office, numbers below are made up to make a point.
Total Revenues = $100,000
Expenses of 60% = $60,000
Take home pay of 40% = $40,000
After medicare and third party linked contracts get cut 20%, possible loss of revenues averaging about 15%. Also expenses seem to always go up 5-10%, so let's use the 10% scenario.
Redo the numbers:
Total Revenues down 15% = $85,000
Expenses up 10% = $66,000
Take Home pay now is $19,000
So what we are really looking at is a 50% drop in take home pay, with a new overhead percentage of 78%
This is probably worse for docs who are getting cut worse for procedures and tests, such as radiologists and cardiologists, who may get cut more than the 20% expected.
Come January, Change is the only thing we can count on.... I have alerted my staff about potential 33% reduction in staff or reduction in work hours to a maximum of 32 hours for critical staff , and 24 hrs. or less for others. 401K contributions : Staff can still pay into it but no matching contributions ..will move any benefits to a cash-balance annuity plan to reduce taxable income. This is to retain the best employees. Will drop Medicaid elective visits to office ..will still continue to see some in- hospital patients purely out of respect for the community we live in. Non urgernt Medicare visits will have to be scheduled selectively and electively, as we may not afford to have staff to do pro-bono care without tax breaks. Have sent notice and received some increase in payment for services from insurance companies. However the increases are under 4% and may not sustain our old biz models. If above does not work, i will strongly consider reduced charge, cash only for services, further staff trimming by June. Planning to reduce work days to 4/week. ( Mon-Thu)...
I just completed the first module of the interactive CME. It was helpful and I look forward to the other modules.
I have had a cash-based practice since 2005 and it was the best thing I ever did for me and my patients. I have insurance companies asking me to join their networks because we have shown we can see their patients for much less and with more convenience, better quality, and higher patient satisfaction then their own providers.
I have also been able to show them that I don't need them to thrive and therefore have changed my bargaining position with them from bent-over and hog-tied to a position of equal status.
If more of us could do this, we would gain more power collectively and could change the balance of power
Depending upon your specialty, you might transition to a "Pictures of the Presidents" plan. You provide care, the patients provide papers with Pictures of the Presidents!
(At this point, pictures of Andrew Jackson predominate)
I already do this for a few patients who have no coverage. This can be organized on a concierge basis or pay as you go. If you feel charitable to a patient, drop his fee, if you want some government subsidy, you can engineer this into the plan too.
When I do it, I record my income. I don't take checks and expect 100% payment at time of service--my fees are discounted so I will not spend an extra penny chasing after payment.
I'm concerned that our short term need to be financially viable is going to continue to lead to the long term devaluation of our profession, as doctors and not just insurance company "health care providers",in the way of allowing more and more PA/NP increases in their scope of practice, and reducing further and further our own scope, especially with regard to procedures and hospital care. Pick up an NP or PA journal sometime-they spend far more time and space discussing ways to further their own profession than we do. if anything, we just spend pages and pages of downers with little attempt to enliven -- I really and truly hope the PME will be able to address this issue and again, not just short term financial gains at the risk of our profession's future.
In Massachusetts, health insurance is mandated for everyone. If someone does not have health insurance through an employer, that person must buy health insurance or be charged a penalty. Great thought. Now almost everyone is 'covered', right? So now they are all paying for health insurance thinking they can swipe their cards and get health care. However, there are not enough primary care docs to take care of all of these newly insured people. Not many docs are going into primary care because they can't afford to practice primary care.
I would love to open a cash only pediatrics practice. It would be a low overhead, high tec and 'high touch' practice, modeled after L. Gordon Moore's work. www.aafp.org I could charge less because I would not have to employ an army of insurance specialists, insurance coders and billers. I could donate my services without violating some contract. Think about it: Taking good care of patients, taking time to be with them and help, and reducing the cost of medical care, reducing stress. What a concept!
The cost savings could be considerable. I understand that the average doctor spends about $65.000. a year to take care the insurance generated paperwork.
I do have concerns that a cash only practice would not be possible in an insurance mandated environment. Patients are already paying their monthly insurance premiums, expecting to pay only their co-pays or deductibles at appointments. It's not entirely clear if doctors will be mandated to accept the insurance 'contracts'. Keep in mind, that the McCarran-Ferguson Act 1945 gave insurance companies certain immunity from FTC regulation. Doctors do not have that immunity. The playing field is not only not level, it is rigged. The rigging is not in the favor of doctors and patients. prescriptions.blogs.nytimes.com
Further, Massachusetts is moving toward a 'bundled' payment system in which the whole team of doctors treating a patient will divide up any reimbursement. This is supposed to be implemented sometime in the next five years. Yes. Our state medical society seems to be on board with this 'reform'. The goal is an admirable one of better coordinated care, however, I wonder what new level of bureaucratic arcana, machination and cost will be required. Sadly, I fear doctors will be pitted against doctors to get their pittance under this 'new' scheme. Despite good intentions by all, patients may be caught in the fray with less coordinated care and still higher costs. More doctors will leave primary care medicine. More doctors of any kind may leave.
Some of my colleagues are currently getting 'reimbursements' for less than their cost to provide the service. Other colleagues are surviving in practices that are subsidized by various agencies. Other colleagues are employees of the large hospital systems. Most are on hamster wheels running as hard as they can, trying to help patients one after another or at the minimum, trying not to hurt anyone.
Cash practices are disparagingly called, concierge practices. But cash practices may be the only salvation for healthcare, the only way to dislodge the giant insurance industry that has wedged itself between doctors and our patients.
Sermo Doc 12 illustrates well the importance of physicians being tech savvy to the level of running their business with one staff member. It is not practical to have a front office person, check in person, chart person, coder, biller, nurse, Assistants, PAs etc. It is just suicidal to employ so many people and work to death trying to pay salaries. This is where electronic records with built in billing features, smart phones with bidirectional connection to scheduling software where the doc makes his own appointment will become relevant. With either single payer or mandated insurance systems like in MA, physicians will have to shape up and practice smarter or decide to retire. Those who choose not to be tech savvy may not be employable ( will be seen as a nuisance) in larger groups. ..We cannot continue to work like hamsters. Even Hamsters need to eat and feed their families...
Thanks Dan for your efforts. While you have prepared more formal structure for this concept now, I have spent last 2 years planning my new practice on similar concepts. It has been only 3 months since I opened it and it is too early for me to boast, but so far it looks good and some day when Sermo tech staff is able to find out the glitch that prevents me from posting new posts, I will present my experience to my fellow Sermoans.
I can run my practice in the back area of a large SUV with one laptop and a cellphone. Most common feedback I am getting from my "consumers" is that I spend a lot more time than they could believe and word of mouth is already a significant part of my game. So far I am happy and my patients are happy.
---------------------- About pay cuts: There are several threats that we see coming- 21% cut, abolition of consult codes, revaluation of "misvalued" services and whatever else lies in "reform" bill. I, however, see an opportunity in this adversity. I need my patients to feel sicking tired of hamster wheel operations. That will help me get more patients. I can afford to do so as I run lean operation, even if I accept insurance payments as full. My only limitation at this time is that I dont have enough volume to be able to show my middle finger to insurances. Accepting insurance is a political necessity in my new practice as referring docs get delirious when I try to explain to them micro-practice model and get seizures on the thought of canceling even their worst payer contract. My cash charges are lower than their worst payer and I am very happy with that. I feel satisfaction in spending more time with patient and less time with some high school drop out trying to teach me medicine from a cubicle in ins co office.
--------------------- On a more fundamental level, you can see that Govt is all too focused on **insurance coverage** rather than healthcare access. It is a major distortion from real issues. I do not see things getting more sensible. Patients will suffer most. Doctors who do not wake up to the reality and get rid of addiction to 3rd party pay system will face bigger challenges. As a fan of principle of seeing competition as the driving force of progress, I sure am licking my chops seeing their practices foreclose.
When I see cash patient, only paper I or pt see is green paper that says "In God We Trust". That is how paperless my practice is. Sometimes even that is not in picture when I charge their credit card online.
This is nothing new. Those of us in direct practice left the financially "dominated" medical care system years ago in order to work for our patients. There is now data that demonstrates that those patients who invest in their own health spend fewer overall dollars but "get more for their bucks." Quality health care can be nourished in a competitive, transparent marketplace. I have asked Congress to PLEASE allow for private contracting in this legislation as a means to control cost and improve quality. In the meantime, we (doctors) can start to post our cash prices in our offices and demand that our hospitals, surgery centers, imaging centers and laboratories do the same. Finally, you might want to look at MediBid as a means of increasing your opportunity to work more directly for patients from all over the world. Thanks for bringing this discussion to the table.
I do see the 21% drop in reimbursement across the system as both disaster and opportunity.
The prevailing belief is that all involved on the provision side are greedy and gouging. Once the reduction goes into effect nearly all large facilities in my community will go under, as I happen to know that the hospital is scraping by at an anemic 2% margin - which will improve a little as it also has 1.5% "free" - unpaid for service. This large hospital doles out > 1 million a year to sustain the local top heavy, high overhead clinic.
While the local solioist and small practices that are non proceedural may be able to restructure as their net goes < 50% prior, the big ones are going to crash hard, and as they sink, take communities with them.
This is a good thing. The ensuing disaster will teach the entitled a new perspective on the cost of caring for them, and also the value of those "overcharged" prices.
Let them eat cake - see a PA in wallmart getting 40K a year.
I have been in a group of "concierge" physicians for over 4 years and do not regret it one bit. Our model still bills patients and their insurance for medical care, but we receive an annual fee for performing sreening and preventive care that is not covered by Medicare and other carriers. Yes, I have been terminated by some payors, but the annual fee constitutes 75-80% of my income. Therefore, I am not affected as much by changes in reimbursements. I am doing well with only 325 patients in my practice.
Any primary care physician who has more than 600 patients over 55 y/o should e-mail me for more info. drseligmann@mdvip.com
One version of "partial concierge" is not accepting NEW patients from carriers that under reimburse, or collect patients with problematic behavioral trends.
In otherwords, most specialists these days are not accepting medicaid and giesinger. (these 2 are often being mentioned by the prevaing party these days).
Will this "partial" group excluded now extend to medicare?
ie: maintain current patients to prevent disruption, new medicare patients will have to travel to tertiary centers at great inconvenience to them?
This will severely effect rural seniors, but after all, Dr Obama thinks that rural pennsylvanians cling to their guns (right to bare arms) and religion (conservative). I can think of more than a few democratic voting seniors who will not be happy to drive 2 hours on the crappy pennsylvania roads to the big city.
No one model that can fit everyone in an open marketplace. Internists, Pediatricians and family physicians can certainly make a real comeback with cash-only, value added services. They ought not to miss this golden opportunity to offer value and worth to their patients in these difficult times. Very expensive elective surgeries like Orthopedic, ophthalmic,elective general surgery, certain types of cardiac and neurosurgery, almost all but emergency urologic procedures, Oncologic therapy, cutting edge treatment like stem cell therapy will most likely be done in countries outside USA unless we get rid of the ridiculous melodramatic plaintiff lawyers fishing for multimillion dollar awards for pain and suffering. These cutting edge surgeons may set up shop in ships floating outside US waters or in places like Baja-California, setting their own rules of service. No matter how much we rant about mishaps, these surgeries are being done all over the world consistently well and most conventional arguments against such outsourced services will fall aside when affordability becomes an issue. Specialists like endocrinologists, GIs, Nephrologists would do well to form large groups to get better market leverage and reduce cost of doing business. Trauma Surgeons and ED specialists will be in great demand with increasing acute illness, gunshot wounds, terrorism related trauma, infectious diseases, etc. Eventually market forces will force these tectonic shifts in biz practices. we are already seeing this. Patients routinely override their physicians and get help from outside. ( about half a million US citizens went abroad for treatment last year. Psychiatrists can certainly set their own prices for their services. plummeting economy will create huge clientele for them.
sorry I did not mention radiology..They voluntarily surrendered their license to practice to Nighthawks..a few years ago. The future radiology departments will be headed by radiology NPs!
Much like the last few years, the threat of cuts loomed but we were "saved" at the last minute, right?
Wrong. The overall rates weren't cut, but the geopraphic factors, and other coefficients were adjusted so the the end result was that most codes were actually reimbursed at less than the year before.
It doesn't take much to confuse the situation, as there are so many variables and factors that are played with, we cannot possibly stay on top of it all. That is what CMS and Obama count on. That is the source of power, look at the right hand while the left is proceeding with a digital exam [sorry for being crude].
Why is it that were play into this? Why should we be thankful for a "save" ? Why are we thankful for clear undervaluing of our trade/skills and training? It confuses me daily.
Cuts or not, cash is king and always will be.
Whatever business model we subscribe to, the bottom line is that there has to be a payment for a service. The safest thing is for the patient to pay for that service, and let them fight the insurance for reimbursement. I wonder how well it would go over, if we were paid, and the patients got the EOB/denial with requests for documents/literature?
Today Clark Howard on his CNN segment about " Don't get ripped off.." touted medical tourism as a viable option for prevention of illness related bankruptcy! Doctors can choose to retire into their cocoons of comfort or come out and confront the competition by providing value to people for money they spend. This is a rare opportunity to kill the third party system of payment for medical services. .
I am in an executive MBA program and relatively new to posting and following on Sermo. I have already "met" a lot of docs here with a lot of great ideas and many that have already started or plan to start innovative practices using sound business and economic principles that will prove to be successful--regardless of what Obama, Reid, and Pelosi ram down our throat (unless they downright outlaw cash based practices).
It took me twenty years after medical school to pursue my MBA and in the very first year, I learned more about business and economics than I had learned in the last 20 years of practice and have been able to apply that knowledge to my already successful cash based practice to make it even more successful.
My point is that, I believe that it is our relative collective ignorance in business and economics that has brought us to the brink of disaster and that has us in the current situation of not having a seat at the bargaining table of healthcare reform with politicians, lobbyists, the businessmen that run insurance companies, and the public.
We are currently only spectators in this debate with marginal input through various groups such as the AMA (who we all know has their own agenda and do not represent the majority of us) because we abdicated our responsibility as caretakers of health care to the bean counters and administrators of the insurance companies and HMOs a long time ago while we were too busy concentrating on caring for patients.
There was no reason for any of us to "worry" or think about the business side of medicine as we were all happy and making a good living for a long time. But then we woke up one day, and found that we were no longer in charge, now we were mere technicians and pawns in an industry rather than a profession.
For a while, this was ok as we were still getting paid relatively well, although we all know that year after year we kept taking hits and our incomes were coming down. Still, we did nothing in terms of educating ourselves and positioning ourselves in the business of medicine and we let the groups and associations fight the battle for us in Washington against Medicare cuts. Afterall, we all knew that as Medicare went, so did the insurance companies.
Now we find ourselves completely pushed out of the picture, again with only a spectator's seat in the current battle. If we speak up, we are told to shut up--by both the public and the politicians--as we are though of as meaningless cogs that only provide the service and we should be happy with what we have--afterall we are in the top 5% of income.
So here we are, wringing our hands wondering what the hell hit us and bitching and moaning on blogs, Sermo, and Medscape and whatever other discussion groups are out there. Many have good things to say and great ideas to put forth, but those ideas and suggestions are not being translated into action as we all suffer from the Don Quixote syndrome. Instead, we moan and gripe and even bicker amongst each other (imagine that) all wishing that somehow things would get better, but resigned to the fact that things will only get worse.
Once in a while, our spirits will be lifted by a great post like that of webdoc1 or the flame of fight and resistance will briefly flicker with a post from dximgr, or rarmstrong, or Sermo Doc 6 but quickly dies out as we all realize that we either don't have the energy, the time, or--more importantly--the cohesiveness to don our armor, collect our arms, and demand our rightful place at the head of the table that was handed down to us and entrusted to us by Hippocrates himself.
We call ourselves a fraternity, yet we are most often motivated by our own self-interest, rather than the welfare of our noble profession. It is a shame when other "groups" or "fraternities" like the UAW and AARP have a seat at the bargaining table in discussions that will determine our fate, while we are THE principals at the center of the debate.
I laud your leadership and your efforts in starting the Practice Management Exchange. I hope that all of us take advanatge of it to educate ourselves above the clinical aspects of medicine. I would love to see it expand to include modules in management, economics, finance, organizatonal behavior, health policy, negotiations and communicatons, information technology, public health, and accounting--all the things that we might see in an MBA or MMM (Master in Medical Management) program.
I know there are several MD/MBAs and students on Sermo and many that should be if they don't have the degree. I would love to see us come together to network and help you in this endeavor to perhaps develop curricula and modules for our brethren that are too busy to go for an advanced business degree, but still want to learn.
It is only through knowledge and collective action that we will ever hope to regain our mantle of authority in the current battle for our profession.
John R. Vigil, MD, FACPE
Fellow, American College of Physician Executives
CEO and Medical Director,
Doctor On Call
Cheers Sermo Doc 6! You are correct in that we need to take risk to succeed in these changing times. You are also correct about the opportunity to kill the third party system which provides NO VALUE ADDED to the care of our patients. Let's consider making lemonade out of the lemons coming our way.
In case you guys haven't noticed there isn't a huge line of people waiting to do our jobs.
I am so glad to have retired and doing locums 1/2 time.I enjoy medicine again,have control over my professional life,minimal overhead no Insurance hassles-i wish I had done this sooner.Dan you are doing a great job standing up for the practising physician who is usually left out of the decision making process.We now have a forum.
A much needed forum. Some areas of the country with entitlement mentalities will be much harder to switch to cash based practice. One of my offices in Youngstown, OH has so many patients that convulse and refuse to pay a ten dollar copay. Every time I am there I see these same patients plunk down $400 for designer eye glass frames ( to the optician, unfortunately not to me). Those same patients also spend more than ten dollars on lunch.
I would love to see some accounting on the cost it takes to deal with insurance companies.
In my office for example:
Front desk person, Nurse and Office Manager/Biller- Could eliminate one of these
Computer system and EMR/Billing Software-Could get rid of completely
Time spent on preauths, appeals of denied claims, mandated requirments ettc
Cut down on phone bill, copy bill, paperwork
Belonging to local IPAs for better contracts
I believe if we removed third party payers from the mix, supply & demand would provide a range of fees that would accommodate our patients and enhance our practice of medicine. We made a huge mistake when we sold out to the insurance companies to gain competitive advantage. Costs would be lower and patients happier. To accomplish this we would have to hang together and represent a strong majority of the physicians , including both primary care & specialists. We would also have to structure the business model carefully to avoid antitrust concerns.
I can't drop insurance companies because I'm a surgical subspecialist (ENT). My patients would just go to another ENT in town that accepts their insurance, even if I did charge less. I discount about 20 - 40% for cash-paying patients without insurance, and could do just fine. The decrease in work for my office staff would be huge, and I wouldn't have to contract with a billing service for thousands of dollars a month.
Right now I am not practicing out patient clinic anymore,used to in past,may go back in future.My concern about cash practice is not having enough business without insurance.I have not tried it,can't tell how will it work.
As long as most patients have insurance, and can't afford to pay for their own care, most doctors will not have the luxury of only taking cash, unless they are the only doc in the region, or in a region with a lot of rich people who can afford it. Reform has to come at a national level. We have to be paid a reasonable amount, and everyone has to be covered by the system so we don't have problems with patients who can't afford care.
Sermo Doc 24 is correct - if we set a "drop 3rd party payers day" and sent in post dated resignations from all insurance plans, and say 70% of private practice physicians did it then we could control the agenda. Post dated resignations from State controlled healthcare systems have worked previously in Britain, France and Israel.
If the 21% cuts happen my own practice (PCP group of 7 providers in Northern CA) will not drop Medicare immediately, we cannot sustain that cash flow loss, but we will close to new Medicare patients comepletly, if the major private payers here, BS, BC, United, Aetna, tried to follow suit we would cancel our contracts and go out of network and develop our own cash pay and retainer practice for non Medicare patients. Then when we are ready we will drop Medicare and offer those patients cash pay services also. Enough is enough - and yes we would save substantial billing and collexction costs, given a severe shortage of PCPs we are not so worried about patients going elsewhere, there is nowhere else in our small town - the other PCPs are all saturated, My biggest concern is that aptient's will not get care - but the pioint has come where we may have to break a few windows to get change.
We alone hold the keys to our shackles and that is to STOP SIGNING UNFAIR CONTRACTS WITH UNSCRUPULOUS COMPANIES. How many intelligent people would sign a contract with someone proven to pay accurately less than 70% of the time? Yet how many of us sign those very contracts every day! We are our own worst enemies.
However, often patients get NO reimbursement for out of network services, and are therefore unfairly penalized for that choice. Medicare leads in this "all or nothing" approach. We need to push for "defined benefit" where plans pay patients a defined benefit for specified non-emergent services but patients can go to whomever they please and providers can charge what the market will bear. Only then, can we truly approach "patient-centered" free-market care.
Dropping Medicaid, Medicare, and now private insurers will only serve to drive more patients into ERs to seek care, overburden those of us who work for major teaching hospitals who won't switch to some "cash only" practice, and/or force patients without ability to pay "cash only" to not seek care at all. There must be a better way.
I already started a concierge practice because I couldn't stand the hamster-wheel...My annual charge are: $600 for kids 0-22 (in college), $1000/yr -20-39 yo, $1400/yr - 40-49yo, $1800/yr - 50-64 and $2000/yr for 65+ ... insurance (if you have it) can pay for labs, xrays and referrals, hospitalizations. If no insurance, then I have fee-based xrays (about $25 for most xrays), send off labs for what I can't do in office (most 1/5th cost of normal lab companies), and nearby MRI/CT/US facilities that have cash rates that are reasonable. Just need a major medical plan for possible hospitalization coverage and patients are set. Very low cost overall.
let us get the patient back INTO the picture...!!! they become responsible again .. and help rather than get mad at us because their insurance co or government no longer pays or cares about them!! and certainly neither care about US!
By building an ecosystem of direct or "concierge" care physicians, we can embed third party free healthcare into the larger delivery system. I've always preached unity, regardless of creed and specialty, among physicians. This is now more important than ever.
I can envision a future where most physicians practice in a direct care setting and as out-of-network providers. If health plans are too stingy, the patients would complain and the fight would be between consumers and health plans. Unlike their utter disregard for physicians, health plans aren't capable of easily ignoring a massive wave of consumer pressure.
The proposed fee reduction will hasten my retirement and many others over 60yrs may have similar thoughts. My practice is in a rural area ; the closest same specialty docs in my field are more than 100 miles away and patients will clearly be inconvenienced, but they voted for change.
I had to vote "no opinion" because technically I would have to answer "no" to the question of whether the fee reduction has accelerated my dropping of third party payers but the reason is because I gave up all third party payers several years ago. As a plastic surgeon this wasn't too hard for me but I'm sure it is for other specialties.
Central planning and wage/price fixing always leads to market distortions and shortages. A lot of government medicine or government controlled "private" medicine will be handled by non-physicians, FMG's, or other physician substitutes.
I've been out with the swine flu and have missed some posts on Sermo but let me belatedly thank you for the leadership you have shown in the HCR arena.
No one can seriously say that Sermo has not had an effect on the health care debate. I am proud to call my self a member of Sermo and contribute in any way I can to it's unfaltering advocacy of physicians and patients.
If patients want to pay me in chickens, eggs, garden vegetables or an old beat up Plymouth Valient, then by all means, let's get the party started. I prefer being payed in pecan pie and fried chicken most of all.
"I Can't" (resign from insurance networks) translates into "They Win" (the insurance companies.) Think outside the box. Take chances. Propose changes you could make to your practice and let MBA's/MBA candidates on this thread and thoughout Sermo help you look at the pros and cons. I am a psychiatrist and in my field of medicine it is easier to transition to a fee-for-service practice model. But it is not impossible for any MD to do the same...you may need to change the way you practice and the initial income you can expect, but we MUST believe it is possible or we are all just "blowing off steam."
Sermo Doc 14...non-participating Medicare is little more than participating. You get about a 7-12% bump in payment BUT you still have to do the billing on behalf of the patient. You also have to worry "did I do all the HICFA 1500 boxes correctly" or be accused by Medicare of fraud at treble damages. The entire Medicare system is a bust. I opted out and did not look back....
But, I believe, one can go non-par anytime but opt out only during elk mating season ie October I would rather go non-par in jan and of course do opt out next Oct than stay par in Jan and then wait for the Elks
Seeing so many good ideas above, I don't know what everyone is so worried about. We're much smarter than the bureaucrats that are our payors. We should just keep posting new ideas until everyone agrees on one. Then we can hope that every other doctor in the country joins sermo, reads the post, and agrees. Then we can tackle something more difficult.
History has shown that we are politically inept and do not have the 'lobby' that others in our industry have. That is not say that it is a bad thing, we spend our day caring for patients and making decisions one on one- with the patients best interest in mind. If we are lucky we have enough time to get home and spend time with our family. My business model is a fluid one have a mix of third party payors/ self pays. As a private practitioner who STILL goes to the hospital I marvel at how quickly physicians have relinquished in patient care to hospitalists. It is important to see and be seen - by colleagues and patients. The interaction is one that allows for a greater exchange of ideas, information and best practices. The business benefit is that there is no overhead: no rent, staffing issues, gas and electric to be paid. So, when my colleagues state they make more in their offices...do they really? That is but one example of bad management/ business decisions that have plagued us all. I have avoided those pitfalls by remaining proactive no matter what the circumstances or inconvenience. It serves a greater purpose- the maintenance of my practice/ business/ livelihood. So I say to all of you who care to read this post- adapt, adapt adapt. Consider retaking what you have so freely given up. The result might surprise you.
I fail to see how we can lay the blame for the multiple, long-standing woes of our profession at the feet of President Obama, who has been in office for less than a year, and was handed both a huge deficit, as well as two wars, as well as a failing banking system the minute he took the oath.
Yes, I voted for him, and yes, I still think he will do a better job than either McCain or Palin.
Pam, the anger that is espoused here is partially the result of the fact that Barack Obama is the current president, and as such, he owns the problems. Fair or not, it's his watch we are on.
Now, the other part is that he has promised to "reform" health care. And in that litany of broad promises he has made statements(in campaign mode) that are completely at odds with what his democratic allies in congress are crafting and saying.
It doesn't take much common sense to look over the recent house bill and see that this will only make things much worse, not only for our profession, but for the future of America. He is a smart man. If he goes along with this misguided plan, then I lose all respect for his intelligence and his abilities.
He needs to BE the President. He needs to BE a leader. So far all I see is a politician in perpetual campaign mode. The public is seeing it, too. He doesn't have a whole lot of time to switch gears or he and his party are in trouble.
the only two things that have to be changed in health care are: 1. Guarantee to balance bill patients, and that means ALL patients. This is the only way to insulate us from the further reduction in pay. Once we are independent to bill what we need - as the dentists still are - they can do whatever they want with "reforms" 2. Create "patient's Comp" analog to workman's comp - leaves the lawyers out of medicine - tremendous savings while giving better compensation and predictable compensation to those that deserve it
And, Dan, thank you for taking the initiative once again! Great new section! Sadly, I would welcome the 21% paycut. It hopefully would wake up the sleeping colleagues to what is going on. 21% paycut - government medicine in action!
I have a one day a week cash only practice. Most of my patients have private insurance, but are quite willing to pay. I charge less than half the usual fee in my specialty, psychiatry, and offer general practice care if needed. No paperwork, nice cash flow, less tension. Wish I did it full time. Maybe some day.
abc: you can balance bill now. just drop third parties and "bill" whatever you want to your patients. No govt or insurer to deal with!!
But I know you know that.
I too welcome the medicare pay cut.
I hope it will wake up the physician masses to finally decide to drop out of this system.
remember as i posted up at the beginning of this thread, when medicare drops fees, so will the other third parties, as most are tied to medicare rates.
I agree FFS is the only way to go. If most of us did it, therein lies the leverage. Third party payers will have lost their control over us. The time is now. Will the silent majority be true to the task? All that's needed is the decision to retake the profession...
January 1st Managed care is raising rates 20% and copays are tripling. Where is the media on this? Managed Care Executives are not being cut in reimbursement by 21%? I am completely baffled that after a year of Americans learning about executive rip offs in the Financial and Auto industries that Congress and the media has ignored the financial rip off of Managed Care and now is handing over the 40 milion uninsured to be pick pocketed like the rest of us. Someone has got to stop this crime!
I agree that fee for service is the way to go. We are lucky at our hospital that we have not had a lot of pressure to contract with all insurers and IPAs. We give patients breaks when they need them. Unfortunately, we cannot not accept Medicare because as anesthesiologists with an agreement with the hospital, we must do accept. This is the situation will all anesthesia groups (that I know of). So we are beholden to MC fees (which for us are only 30% of private insurance payments, unlike most other physicians, who get 80% of private rates from MC). Apparently the new House bills, HR 3962 (will allow MDs to negotiate rates in the public plan) and HR 3961 (will eliminate the flawed SGR formula and delete the planned 21% fee cut for 2010) are moving quickly and may actually be tolerable overall (although some portions are not). Please contact your Senators, as they are working on their version which reportedly will punish us all fiercely: leave intact the 21% cut, punish us for PQRI, allow a regulatory group to decide unilaterally about future rate cuts. This is being done NOW, so please contact your Senator NOW and tell them NOT to punish physicians in their plan!
Bravo, Dr. Dan. As a retired anesthesiologist, I am closely following the current debate and this blog allows me to get an unvarnished look at life in the trenches. Sermo Doc 23: very well said. PamCobb: you should know better. Drjrvigil: I am getting my e-MBA here in Denver, and I will try to contact you. I have an interest in MDVIP. I am embarking on a business plan which might interest you.
Lest you forget, we already have government sponsored health care-- it's called medicare, and it is a miserable failure. The government can't even run a cash for clunkers program properly- and they expect to enact a complete health care program?
I vote for cash paying practice and do moonlighting where you are just paid by the hospital per hour if you want to work. You have control of your time , you don't deal with insurers.
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 drop CPT codes, ICD codes, and all other such worthless resource-eating bullshit (pardon me - no other word suffices) we've allowed the government and insurers to impose on us, and present bills in plain language. Our ONLY CONTRACTS and our ONLY NEGOTIATIONS should be with our patients.
We should 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. Or, maybe insurance will revert to it's only valid purpose, protection against CATASTROPHES.
In the meantime, WE WILL BE FREE from all the ridiculous interference we've only tolerated 'til now because it was inflicted in such a gradual, insidious manner. Our overhead will go down DRAMATICALLY, along with our frustrations and inefficiency; while our joy of practice, patient satisfaction, and YES, even our financial fortunes will once again trend upward.
This doesn't require a "lobby," a union, or even a rehabilitated AMA. We are free professionals practicing in a free land. We just need to stand up individually for what is right for both our patients and ourselves. Communicating our motives and goals with our patients, and gradually withdrawing from the insanity of Medicare, Medicaid and insurance are key.
Sermo Doc 52...says: "AMA is a member organization. Why do non-members care what an organization does to which they are not members? "
Why?? for the same reason we care about Al Qaeda..They are a member organization with a microscopic fraction of US citizens as its members..but look at the havoc they can cause in our lives. Living in our midst and hijacking our collective work and name, .AMA has the same pernicious effect
exactly AMA acronym now officially stands for Al Medica Asso or Al-Maeda or ....? they have done more damage and cost more moeny to the US than Al-Qaeda has. Healthcare would not be so expensive if it were not for AMA's clever scam of CPT coding
Fox TV needs to send their undercover operatives to take video film of AMA's functioning just like they did for ACORN .......... results would be similar.
Public reading these notes should call their congressmen to investigate AMA's financial books
When the Medicare rates drop 20%, so do all your other contracts tied to Medicare.
So if say that is a 15% drop in revenues, but the same 5-10% increase in expenses....
and with an overhead of 60% for a FP.....
that leaves 40% premedicare cut for takehome pay...
to a
25% post-medicare cut for take home pay....
leads to a 37.5% cut in your take home pay!!!
1) Join a big group that has leverage to negotiate
2) Work as an employeed physician
3) Drop third party contracts now, and become a doctor who first and foremost cares for patient's at whatever reasonable and amrketbl fee you decide... You can also waive fees to the needy without worrying about getting sued by the government!!!
I think you know where I stand ; )
Summarily, these pateints are willing to pay CASH ONLY basis! For hospital and emergency visits, a catastrophic insurance would be most acceptable!
Their awareness of the current system has matured to patient NEGLECT and UNDERSTAND (un)SGR which they attribute to MISTRUST in governmental politics and mishandling the current economy. Along with their in-bed relationship with the third party system and their vested financial interests ANY private inusrance /public option proposals will be MET by patient doctor disgust, skepticisnm and as had been predicted will never succeed!
ANY PME recommended by the SERMO docs are undoubtedly supported by these patients who had put their TRUST-CONFIDENCE in their choice of doctors and entrusting their health care!
The continuous dialogue between the dr/pt relationship is NO SUBSTITUTE to a genuine health care and undoubtedly remains as the key to a successful health care delivery system!
All other current proposals/reforms in the health care industry will REDOUND to POLITICS as USUAL regardless of party color and the current economic crises may ignite a people upheaval as displayed in all of this town meetings and online responses !!
For a small family practice office, numbers below are made up to make a point.
Total Revenues = $100,000
Expenses of 60% = $60,000
Take home pay of 40% = $40,000
After medicare and third party linked contracts get cut 20%, possible loss of revenues averaging about 15%. Also expenses seem to always go up 5-10%, so let's use the 10% scenario.
Redo the numbers:
Total Revenues down 15% = $85,000
Expenses up 10% = $66,000
Take Home pay now is $19,000
So what we are really looking at is a 50% drop in take home pay, with a new overhead percentage of 78%
This is probably worse for docs who are getting cut worse for procedures and tests, such as radiologists and cardiologists, who may get cut more than the 20% expected.
Is this the change we can depend on????
I have alerted my staff about potential 33% reduction in staff or reduction in work hours to a maximum of 32 hours for critical staff , and 24 hrs. or less for others.
401K contributions : Staff can still pay into it but no matching contributions ..will move any benefits to a cash-balance annuity plan to reduce taxable income. This is to retain the best employees.
Will drop Medicaid elective visits to office ..will still continue to see some in- hospital patients purely out of respect for the community we live in.
Non urgernt Medicare visits will have to be scheduled selectively and electively, as we may not afford to have staff to do pro-bono care without tax breaks.
Have sent notice and received some increase in payment for services from insurance companies. However the increases are under 4% and may not sustain our old biz models.
If above does not work, i will strongly consider reduced charge, cash only for services, further staff trimming by June.
Planning to reduce work days to 4/week. ( Mon-Thu)...
I have had a cash-based practice since 2005 and it was the best thing I ever did for me and my patients. I have insurance companies asking me to join their networks because we have shown we can see their patients for much less and with more convenience, better quality, and higher patient satisfaction then their own providers.
I have also been able to show them that I don't need them to thrive and therefore have changed my bargaining position with them from bent-over and hog-tied to a position of equal status.
If more of us could do this, we would gain more power collectively and could change the balance of power
Join us!
(At this point, pictures of Andrew Jackson predominate)
I already do this for a few patients who have no coverage. This can be organized on a concierge basis or pay as you go. If you feel charitable to a patient, drop his fee, if you want some government subsidy, you can engineer this into the plan too.
When I do it, I record my income. I don't take checks and expect 100% payment at time of service--my fees are discounted so I will not spend an extra penny chasing after payment.
Good faculty so far too.
Great thought. Now almost everyone is 'covered', right? So now they are all paying for health insurance thinking they can swipe their cards and get health care. However, there are not enough primary care docs to take care of all of these newly insured people. Not many docs are going into primary care because they can't afford to practice primary care.
I would love to open a cash only pediatrics practice. It would be a low overhead, high tec and 'high touch' practice, modeled after L. Gordon Moore's work.
www.aafp.org
I could charge less because I would not have to employ an army of insurance specialists, insurance coders and billers. I could donate my services without violating some contract. Think about it: Taking good care of patients, taking time to be with them and help, and reducing the cost of medical care, reducing stress. What a concept!
The cost savings could be considerable. I understand that the average doctor spends about $65.000. a year to take care the insurance generated paperwork.
I do have concerns that a cash only practice would not be possible in an insurance mandated environment. Patients are already paying their monthly insurance premiums, expecting to pay only their co-pays or deductibles at appointments. It's not entirely clear if doctors will be mandated to accept the insurance 'contracts'. Keep in mind, that the McCarran-Ferguson Act 1945 gave insurance companies certain immunity from FTC regulation. Doctors do not have that immunity. The playing field is not only not level, it is rigged. The rigging is not in the favor of doctors and patients. prescriptions.blogs.nytimes.com
Further, Massachusetts is moving toward a 'bundled' payment system in which the whole team of doctors treating a patient will divide up any reimbursement. This is supposed to be implemented sometime in the next five years. Yes. Our state medical society seems to be on board with this 'reform'. The goal is an admirable one of better coordinated care, however, I wonder what new level of bureaucratic arcana, machination and cost will be required. Sadly, I fear doctors will be pitted against doctors to get their pittance under this 'new' scheme. Despite good intentions by all, patients may be caught in the fray with less coordinated care and still higher costs. More doctors will leave primary care medicine. More doctors of any kind may leave.
Some of my colleagues are currently getting 'reimbursements' for less than their cost to provide the service. Other colleagues are surviving in practices that are subsidized by various agencies. Other colleagues are employees of the large hospital systems. Most are on hamster wheels running as hard as they can, trying to help patients one after another or at the minimum, trying not to hurt anyone.
Cash practices are disparagingly called, concierge practices. But cash practices may be the only salvation for healthcare, the only way to dislodge the giant insurance industry that has wedged itself between doctors and our patients.
While you have prepared more formal structure for this concept now, I have spent last 2 years planning my new practice on similar concepts. It has been only 3 months since I opened it and it is too early for me to boast, but so far it looks good and some day when Sermo tech staff is able to find out the glitch that prevents me from posting new posts, I will present my experience to my fellow Sermoans.
I can run my practice in the back area of a large SUV with one laptop and a cellphone. Most common feedback I am getting from my "consumers" is that I spend a lot more time than they could believe and word of mouth is already a significant part of my game. So far I am happy and my patients are happy.
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About pay cuts:
There are several threats that we see coming- 21% cut, abolition of consult codes, revaluation of "misvalued" services and whatever else lies in "reform" bill.
I, however, see an opportunity in this adversity. I need my patients to feel sicking tired of hamster wheel operations. That will help me get more patients. I can afford to do so as I run lean operation, even if I accept insurance payments as full. My only limitation at this time is that I dont have enough volume to be able to show my middle finger to insurances. Accepting insurance is a political necessity in my new practice as referring docs get delirious when I try to explain to them micro-practice model and get seizures on the thought of canceling even their worst payer contract. My cash charges are lower than their worst payer and I am very happy with that. I feel satisfaction in spending more time with patient and less time with some high school drop out trying to teach me medicine from a cubicle in ins co office.
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On a more fundamental level, you can see that Govt is all too focused on **insurance coverage** rather than healthcare access. It is a major distortion from real issues. I do not see things getting more sensible. Patients will suffer most. Doctors who do not wake up to the reality and get rid of addiction to 3rd party pay system will face bigger challenges. As a fan of principle of seeing competition as the driving force of progress, I sure am licking my chops seeing their practices foreclose.
I have asked Congress to PLEASE allow for private contracting in this legislation as a means to control cost and improve quality.
In the meantime, we (doctors) can start to post our cash prices in our offices and demand that our hospitals, surgery centers, imaging centers and laboratories do the same.
Finally, you might want to look at MediBid as a means of increasing your opportunity to work more directly for patients from all over the world.
Thanks for bringing this discussion to the table.
The prevailing belief is that all involved on the provision side are greedy and gouging. Once the reduction goes into effect nearly all large facilities in my community will go under, as I happen to know that the hospital is scraping by at an anemic 2% margin - which will improve a little as it also has 1.5% "free" - unpaid for service. This large hospital doles out > 1 million a year to sustain the local top heavy, high overhead clinic.
While the local solioist and small practices that are non proceedural may be able to restructure as their net goes < 50% prior, the big ones are going to crash hard, and as they sink, take communities with them.
This is a good thing. The ensuing disaster will teach the entitled a new perspective on the cost of caring for them, and also the value of those "overcharged" prices.
Let them eat cake - see a PA in wallmart getting 40K a year.
The lawyers will be loving every minute of it.
Any primary care physician who has more than 600 patients over 55 y/o should e-mail me for more info. drseligmann@mdvip.com
In otherwords, most specialists these days are not accepting medicaid and giesinger. (these 2 are often being mentioned by the prevaing party these days).
Will this "partial" group excluded now extend to medicare?
ie: maintain current patients to prevent disruption, new medicare patients will have to travel to tertiary centers at great inconvenience to them?
This will severely effect rural seniors, but after all, Dr Obama thinks that rural pennsylvanians cling to their guns (right to bare arms) and religion (conservative). I can think of more than a few democratic voting seniors who will not be happy to drive 2 hours on the crappy pennsylvania roads to the big city.
Internists, Pediatricians and family physicians can certainly make a real comeback with cash-only, value added services. They ought not to miss this golden opportunity to offer value and worth to their patients in these difficult times.
Very expensive elective surgeries like Orthopedic, ophthalmic,elective general surgery, certain types of cardiac and neurosurgery, almost all but emergency urologic procedures, Oncologic therapy, cutting edge treatment like stem cell therapy will most likely be done in countries outside USA unless we get rid of the ridiculous melodramatic plaintiff lawyers fishing for multimillion dollar awards for pain and suffering. These cutting edge surgeons may set up shop in ships floating outside US waters or in places like Baja-California, setting their own rules of service. No matter how much we rant about mishaps, these surgeries are being done all over the world consistently well and most conventional arguments against such outsourced services will fall aside when affordability becomes an issue.
Specialists like endocrinologists, GIs, Nephrologists would do well to form large groups to get better market leverage and reduce cost of doing business.
Trauma Surgeons and ED specialists will be in great demand with increasing acute illness, gunshot wounds, terrorism related trauma, infectious diseases, etc.
Eventually market forces will force these tectonic shifts in biz practices. we are already seeing this. Patients routinely override their physicians and get help from outside. ( about half a million US citizens went abroad for treatment last year.
Psychiatrists can certainly set their own prices for their services. plummeting economy will create huge clientele for them.
Much like the last few years, the threat of cuts loomed but we were "saved" at the last minute, right?
Wrong. The overall rates weren't cut, but the geopraphic factors, and other coefficients were adjusted so the the end result was that most codes were actually reimbursed at less than the year before.
It doesn't take much to confuse the situation, as there are so many variables and factors that are played with, we cannot possibly stay on top of it all. That is what CMS and Obama count on. That is the source of power, look at the right hand while the left is proceeding with a digital exam [sorry for being crude].
Why is it that were play into this? Why should we be thankful for a "save" ? Why are we thankful for clear undervaluing of our trade/skills and training? It confuses me daily.
Cuts or not, cash is king and always will be.
Whatever business model we subscribe to, the bottom line is that there has to be a payment for a service. The safest thing is for the patient to pay for that service, and let them fight the insurance for reimbursement. I wonder how well it would go over, if we were paid, and the patients got the EOB/denial with requests for documents/literature?
I am in an executive MBA program and relatively new to posting and following on Sermo. I have already "met" a lot of docs here with a lot of great ideas and many that have already started or plan to start innovative practices using sound business and economic principles that will prove to be successful--regardless of what Obama, Reid, and Pelosi ram down our throat (unless they downright outlaw cash based practices).
It took me twenty years after medical school to pursue my MBA and in the very first year, I learned more about business and economics than I had learned in the last 20 years of practice and have been able to apply that knowledge to my already successful cash based practice to make it even more successful.
My point is that, I believe that it is our relative collective ignorance in business and economics that has brought us to the brink of disaster and that has us in the current situation of not having a seat at the bargaining table of healthcare reform with politicians, lobbyists, the businessmen that run insurance companies, and the public.
We are currently only spectators in this debate with marginal input through various groups such as the AMA (who we all know has their own agenda and do not represent the majority of us) because we abdicated our responsibility as caretakers of health care to the bean counters and administrators of the insurance companies and HMOs a long time ago while we were too busy concentrating on caring for patients.
There was no reason for any of us to "worry" or think about the business side of medicine as we were all happy and making a good living for a long time. But then we woke up one day, and found that we were no longer in charge, now we were mere technicians and pawns in an industry rather than a profession.
For a while, this was ok as we were still getting paid relatively well, although we all know that year after year we kept taking hits and our incomes were coming down. Still, we did nothing in terms of educating ourselves and positioning ourselves in the business of medicine and we let the groups and associations fight the battle for us in Washington against Medicare cuts. Afterall, we all knew that as Medicare went, so did the insurance companies.
Now we find ourselves completely pushed out of the picture, again with only a spectator's seat in the current battle. If we speak up, we are told to shut up--by both the public and the politicians--as we are though of as meaningless cogs that only provide the service and we should be happy with what we have--afterall we are in the top 5% of income.
So here we are, wringing our hands wondering what the hell hit us and bitching and moaning on blogs, Sermo, and Medscape and whatever other discussion groups are out there. Many have good things to say and great ideas to put forth, but those ideas and suggestions are not being translated into action as we all suffer from the Don Quixote syndrome. Instead, we moan and gripe and even bicker amongst each other (imagine that) all wishing that somehow things would get better, but resigned to the fact that things will only get worse.
Once in a while, our spirits will be lifted by a great post like that of webdoc1 or the flame of fight and resistance will briefly flicker with a post from dximgr, or rarmstrong, or Sermo Doc 6 but quickly dies out as we all realize that we either don't have the energy, the time, or--more importantly--the cohesiveness to don our armor, collect our arms, and demand our rightful place at the head of the table that was handed down to us and entrusted to us by Hippocrates himself.
We call ourselves a fraternity, yet we are most often motivated by our own self-interest, rather than the welfare of our noble profession. It is a shame when other "groups" or "fraternities" like the UAW and AARP have a seat at the bargaining table in discussions that will determine our fate, while we are THE principals at the center of the debate.
I laud your leadership and your efforts in starting the Practice Management Exchange. I hope that all of us take advanatge of it to educate ourselves above the clinical aspects of medicine. I would love to see it expand to include modules in management, economics, finance, organizatonal behavior, health policy, negotiations and communicatons, information technology, public health, and accounting--all the things that we might see in an MBA or MMM (Master in Medical Management) program.
I know there are several MD/MBAs and students on Sermo and many that should be if they don't have the degree. I would love to see us come together to network and help you in this endeavor to perhaps develop curricula and modules for our brethren that are too busy to go for an advanced business degree, but still want to learn.
It is only through knowledge and collective action that we will ever hope to regain our mantle of authority in the current battle for our profession.
John R. Vigil, MD, FACPE
Fellow, American College of Physician Executives
CEO and Medical Director,
Doctor On Call
In case you guys haven't noticed there isn't a huge line of people waiting to do our jobs.
In my office for example:
Front desk person, Nurse and Office Manager/Biller- Could eliminate one of these
Computer system and EMR/Billing Software-Could get rid of completely
Time spent on preauths, appeals of denied claims, mandated requirments ettc
Cut down on phone bill, copy bill, paperwork
Belonging to local IPAs for better contracts
This totals quite a bit every month.
If the 21% cuts happen my own practice (PCP group of 7 providers in Northern CA) will not drop Medicare immediately, we cannot sustain that cash flow loss, but we will close to new Medicare patients comepletly, if the major private payers here, BS, BC, United, Aetna, tried to follow suit we would cancel our contracts and go out of network and develop our own cash pay and retainer practice for non Medicare patients. Then when we are ready we will drop Medicare and offer those patients cash pay services also. Enough is enough - and yes we would save substantial billing and collexction costs, given a severe shortage of PCPs we are not so worried about patients going elsewhere, there is nowhere else in our small town - the other PCPs are all saturated, My biggest concern is that aptient's will not get care - but the pioint has come where we may have to break a few windows to get change.
However, often patients get NO reimbursement for out of network services, and are therefore unfairly penalized for that choice. Medicare leads in this "all or nothing" approach. We need to push for "defined benefit" where plans pay patients a defined benefit for specified non-emergent services but patients can go to whomever they please and providers can charge what the market will bear. Only then, can we truly approach "patient-centered" free-market care.
I can envision a future where most physicians practice in a direct care setting and as out-of-network providers. If health plans are too stingy, the patients would complain and the fight would be between consumers and health plans. Unlike their utter disregard for physicians, health plans aren't capable of easily ignoring a massive wave of consumer pressure.
Central planning and wage/price fixing always leads to market distortions and shortages. A lot of government medicine or government controlled "private" medicine will be handled by non-physicians, FMG's, or other physician substitutes.
No one can seriously say that Sermo has not had an effect on the health care debate. I am proud to call my self a member of Sermo and contribute in any way I can to it's unfaltering advocacy of physicians and patients.
I would rather go non-par in jan and of course do opt out next Oct than stay par in Jan and then wait for the Elks
My business model is a fluid one have a mix of third party payors/ self pays. As a private practitioner who STILL goes to the hospital I marvel at how quickly physicians have relinquished in patient care to hospitalists. It is important to see and be seen - by colleagues and patients. The interaction is one that allows for a greater exchange of ideas, information and best practices.
The business benefit is that there is no overhead: no rent, staffing issues, gas and electric to be paid. So, when my colleagues state they make more in their offices...do they really?
That is but one example of bad management/ business decisions that have plagued us all. I have avoided those pitfalls by remaining proactive no matter what the circumstances or inconvenience. It serves a greater purpose- the maintenance of my practice/ business/ livelihood.
So I say to all of you who care to read this post- adapt, adapt adapt. Consider retaking what you have so freely given up. The result might surprise you.
Yes, I voted for him, and yes, I still think he will do a better job than either McCain or Palin.
Now, the other part is that he has promised to "reform" health care. And in that litany of broad promises he has made statements(in campaign mode) that are completely at odds with what his democratic allies in congress are crafting and saying.
It doesn't take much common sense to look over the recent house bill and see that this will only make things much worse, not only for our profession, but for the future of America. He is a smart man. If he goes along with this misguided plan, then I lose all respect for his intelligence and his abilities.
He needs to BE the President. He needs to BE a leader. So far all I see is a politician in perpetual campaign mode. The public is seeing it, too. He doesn't have a whole lot of time to switch gears or he and his party are in trouble.
1. Guarantee to balance bill patients, and that means ALL patients. This is the only way to insulate us from the further reduction in pay. Once we are independent to bill what we need - as the dentists still are - they can do whatever they want with "reforms"
2. Create "patient's Comp" analog to workman's comp - leaves the lawyers out of medicine - tremendous savings while giving better compensation and predictable compensation to those that deserve it
IS THAT SO HARD TO FIGUE OUT?
Sadly, I would welcome the 21% paycut. It hopefully would wake up the sleeping colleagues to what is going on. 21% paycut - government medicine in action!
But I know you know that.
I too welcome the medicare pay cut.
I hope it will wake up the physician masses to finally decide to drop out of this system.
remember as i posted up at the beginning of this thread, when medicare drops fees, so will the other third parties, as most are tied to medicare rates.
We should 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. Or, maybe insurance will revert to it's only valid purpose, protection against CATASTROPHES.
In the meantime, WE WILL BE FREE from all the ridiculous interference we've only tolerated 'til now because it was inflicted in such a gradual, insidious manner. Our overhead will go down DRAMATICALLY, along with our frustrations and inefficiency; while our joy of practice, patient satisfaction, and YES, even our financial fortunes will once again trend upward.
This doesn't require a "lobby," a union, or even a rehabilitated AMA. We are free professionals practicing in a free land. We just need to stand up individually for what is right for both our patients and ourselves. Communicating our motives and goals with our patients, and gradually withdrawing from the insanity of Medicare, Medicaid and insurance are key.
Dan Jones, MD
www.jonesplan.blogspot.com
AMA is a member organization.
Why do non-members care what an organization does to which they are not members?
"AMA is a member organization.
Why do non-members care what an organization does to which they are not members? "
Why?? for the same reason we care about Al Qaeda..They are a member organization with a microscopic fraction of US citizens as its members..but look at the havoc they can cause in our lives. Living in our midst and hijacking our collective work and name, .AMA has the same pernicious effect
AMA acronym now officially stands for Al Medica Asso or Al-Maeda or ....?
they have done more damage and cost more moeny to the US than Al-Qaeda has.
Healthcare would not be so expensive if it were not for AMA's clever scam of CPT coding
Public reading these notes should call their congressmen to investigate AMA's financial books
www.cms.hhs.gov