I believe the answer is in our hopes for an actual body representing the physcians interests. Not the interests of insurance companies, nor the CPTcodes, nor the hospitals, and not even the patients. We all want good patient care. But notice how under the guise of "patient access and patient care" the patients are not held accountable for their own behaviors, attorney's have no limits on their incomes, hospital reimburements go up, and physicians have been getting slaughtered for a decade.
Who stands up for both PCP's and the specialist? The AMA? I think not! An organization like docs4pc may be the answer. I wonder how a physician's union would be received? On one hand I'm sure they would try to use antitrust laws against this. Remember BO is the union's president, he is pushing for the expansion of unions. This would expose him for the two faced politician he is . Imagine allowing the nurses to unionize but the physicians- well that's anti- trust.
Yes, the McCarran-Ferguson act must be altered or repealed. The Republicans will be forced into advocating this.
ERISA is another abomination that allows all employment based insurance to be deemed not insurance, and governed by federal contract law. Practical implications of this is that plans can jaw bone doctors financially as much as they want, and when the doctor compromises judgment, the doctor bears ALL the malpractice liability
BUT IT GETS EVEN WORSE
The federal anitrust laws in such a way that they stop wherever a STATE regulates.
The states could each authorize collective bargaining by doctors. In the late 90's, Texas, New Jersey, and Washington DC all passed such laws. The DC law was invalidated by the control board that governed DC at the time (Alice Rivlin, Clinton scum appointee)
Texas and New Jersey laws all later watered down and revoked, in Texas that great friend of medicine, Geo W Bush, retard extraordinaire saw to it that the law was never actually enforced,
AMA was never strong on board.
The irony, is that any law passed in DC must be ratified by Congress which never invalidates a law from DC that doesn't involve abortion, so AMA could have tricked Congress into voting for collective bargaining . It didn't.
Dr. Dan, I have been preaching antitrust issues for as long as I have been a member of Sermo. I think physicians have little understanding of the implications of this century-old legislation, and have even less understanding of the applicability to their practices.
The McCarran-Ferguson Act created insulation for the insurance industry that they have exploited to our detriment. Congress—as usual, bought off by Big Business—could care less about "leveling the playing field" between insurers and physicians. Moreover, the insurance industry and the Democrats (remember the Obama tonsillectomy / amputation gaffe?) have vilified physicians in order to garner support for the reduction of our salaries.
The Roaring Fork decision is small peanuts (http://www.ftc.gov/opa/2010/02/roaringfork.shtm). We need to look at the vast oppression exerted on us by the FTC and DOJ. Look at this post to get a better understanding of antitrust law:
BTW, this was the time the AMA legal staff was either negotiating its own settlements with AMA for wrongful discharge or Sunbeam, or settlements with others wrongfully fired, but not thinking about how the law can be used to help doctors.
The insurance industry is not the enemy, only one of several.
Doctors will be exploited so long as doctors are willing to be exploited. We have an absolute constitutional guarantee to petition government, and at the state level we can get our states to authorize collective bargaining. That is the start for us.
It starts with a Supreme Court decision called Parker v Brown and moves through several others.
Real legal advice would be how to use that series of cases.
If you can believe it, the public defenders in the District of Columbia tried to get a few dollars per hour raise and got slammed by a famous antitrust decision when they represented an even smaller percentage of lawyers in DC.
Doctors have to stop getting their legal advice form the defense bar which is just one more exploiter of doctors.
Lobby at the state level using Parker v Brown for state authorization to bargain collectively and then lean on the Republicans to challenge Obama on repeal of the McF act.
That should go a long way towards leveling the playing field.
Pelosi is no fool. She knows that there are many senators, Repos and Demos who will kill the repeal in the Senate. Dodd and Lieberman are only the most obvious wholly owned subsidiaries of the insurance industry. Tennessee is home of the reinsurance industry, so don't expect either Tenn Senator, Coker or Alexander, to back this repeal either, and it goes downhill from there.
Sermo Doc 2, Do we really want to be a "union" and collectively bargain? I think that's likely to be just one more step down the road to socialized medicine or a "single payer" system. I believe we need to individually set our fees, and negotiate only with patients, not third-party payers. We can only be free by getting out of all our Medicare, Medicaid and insurance contracts. Only then can we return to an efficient free-market system where providers compete based on quality and price. Our current system is basically Marxist, with price controls and central management per Medicare. It baffles me why at least a few Republicans aren't pointing that out; and recommending a return to a free-market healthcare economy. Dan Jones, MD www.JonesPlan.BlogSpot.com
Although this is tangential to Dr. Palestrant's excellent discussion, I thought some might be interested to know that the "standard" history of the Sherman Antitrust law is sadly limited, a typical "of course the emperor has clothes" story fed to high school students and absorbed into the common conscience without benefit of critical thought. In fact, Senator Sherman pushed for the law's passage primarily to harm a specific economic and political opponent. The story is found here: www.cato.org
Also of interest are the claims, both fundamentally wrong and yet widely believed, about Standard Oil and their policy of "predatory pricing" that led to the Sherman Act being used to break up Rockerfeller's company. In fact the original claims in a book by Ida Tarbell (The History of the Standard Oil Company (New York: Peter Smith, 1950). Tarbell's brother, William, was treasurer of Pure Oil Company, a direct competitor) were thoroughly demolished on both economic and historical grounds by economist John McGee ("Predatory Price Cutting: The Standard Oil (N.J.) Case," Journal of Law and Economics 1 (April 1958): 13769.) This material is well summarized at: www.cato.org
It seems to me that Dr. Palestrant's take home message is the right one - Don't contract with insurers.
If you have no contracts there can be no anti-competitive behavior at that level. The FTC could still presumably go after small groups of local physicians if they felt they could prove price collusion among competitors, but the chance of that collusion occurring is extraordinarily small, and proving it would be next to impossible.
As an interesting aside, it is accepted as typical and even standard behavior that if an airline changes its rates for a given route, its competitors will very quickly (within days) change their rates to match, and even publicize the event if it happens to be a rate cut. But airlines are regulated under different legislation than is medicine.
What really scares the FTC, though, and every other govt entity involved in physician regulation, is the notion of regulating 800,000 individual practitioners. There was a quote from a govt official in the Wall Street Journal several months ago to the effect that the government is trying to force physicians into organizations (i.e. to become employees) because it is much simpler to regulate a few thousand organizations than 800,000 individuals. I'm sorry that I can't reproduce the actual quote here, but the fact is that the government wants to regulate us, is trying to herd us into employee status in order to do so and has, at least on occasion, admitted to this.
A physicians union is a poor alternative to independent physicians, simply because over time it would almost certainly do as the AMA has done, and as most trade unions do now, and put its own interests ahead of that of its membership.
Eliminating all insurer contracts - private, Medicare, Medicaid, etc, is a difficult move for some physicians, most notably those in large hospital-employed groups. For them, they probably don't have the authority to unilaterally do so without the hospital's approval, which will be difficult, if not impossible to obtain. So they have to consider leaving their current job in addition to refusing contracts. For solo and small group PCPs, though, the market demand for their services is such that it makes no sense for them not to do it, as of yesterday.
While the earliest adopters in a given locale may find a temporary drop in their practice volume, there are many examples on Sermo and elsewhere demonstrating that the practice recovers, and were the majority of PCPs in an area to follow suit, the market would immediately have to rebalance itself anyway. The fear of making the leap is the biggest enemy in medicine today, even more so than insurers or the government. It is contracts, and only contracts, that give the insurers and the government their power over us.
I agree a doctors union would be like trying to get a union of farmers to agree at what price they will sell their hogs. I am curious though how it is not anti-trust when the government can not only price set via it's conversion factor but via collusion( in it's ability to change the rvu's) influence the reimbursement of all other RVU based insurance companies. Show me a over 65 person whose primary insurance is not medicare or an advantage plan. So they have a 100% monopoly on a large segment of the market and it's clients are mandated to choose one of its products. How is that not a monopoly?
So...why is the FTC so very concerned about the 800,000 physicians, and not so much about regulating, say, 650,000 individual CPAs, or the 1,143,358 attorneys in the US? No concern there at all?
And if the concern surrounds the fact that the health care sector encompasses such a large sector of the economy, is there similar concern for the 150,000 dentists, 75% of whom are solo practitioners?
MM: "So...why is the FTC so very concerned about the 800,000 physicians, and not so much about regulating, say, 650,000 individual CPAs, or the 1,143,358 attorneys in the US? No concern there at all?
And if the concern surrounds the fact that the health care sector encompasses such a large sector of the economy, is there similar concern for the 150,000 dentists, 75% of whom are solo practitioners?"
I don't think it's the fact healthcare encompasses such a large sector of the economy, but that it's a portion of the economy paid for, about 50%, by the government. Attorneys and CPAs don't get paid by the government in the same way.
Sermo Doc 5- I think the reason that government wants to control us are two fold. 1) Our decisions drive health care spending, 17% of GDP and rising. 2) Many in government want to expand health care coverage to the poor at minimal cost while maintaining an equal standard of care for all.
seems to me we could make common cause with Speaker Pelosi on this: The repeal of an antitrust exemption of a universally hated industry. Yes, there are certainly senators bought and paid for by the Insurance companies, but there may be enough political will to pass this by reconciliation in the senate, particularly if some Republican senators can be brought on board: Politics does indeed make strange bedfellows.
On the other hand, there is no way the public will countenance an antitrust exemption for physicians. So you just can't do what roaring fork did. The percentage of physicians it involves is irrelevant.
What we really need is the conversion of big health insurers to nonprofits, like they do in the Swiss system. The physicians are left alone, and the insurers compete on supplemental plans. Given that, I personally could live with no antitrust exemption.
Easy fix for healthcare and the economy. Make insurance companies really compete against eachother AND get rid of the employer mandate. If the companies must sell to individuals with true competition prices will go down, service will go up, it will become pportable. IN addition, employers will have more money to spend on job creation. Doesn't cost the governement a dime.
The use of antitrust for purposes other than control of monopoly corporations is of long standing. The very first use of the Sherman Act, for instance, was not against a corporation at all but against Eugene Debs' American Railway Union and its secondary boycott during the Pullman Palace Car Co. strike.
With Roaring Fork, it's naked control, a distortion of any conceivable sense of legislative intent, and worth fighting. I'll say again what I've oft said: it's critical that docs and patients fight together, rather than adopt positions which our opponents would use to turn us against each other. If the goal is cost-effective care, better access and, in general, better patient care, we'll win. If it's merely who has the power, we won't. Don't mistake what I'm saying: these aren't mutually exclusive. But if docs are seen fighting only for themselves--and that's how our opponents will portray us, every chance they get--we'll lose.
Go and read the complaint (http://www.ftc.gov/os/caselist/0610172/100203roaringforkcmpt.pdf). Unbelievable. In the overview section, it states that by contracting with physicians at lower costs, the lower cost would "enable the payors to reduce the price of insurance".
I want ONE example of this. Just one. I GUARANTEE you the is not one case in the entire country where insurance industry agreements with an IPA have lowered the cost of insurance.
My eyes are bleeding. I need to go apply pressure.
The real question is this IPA essentially a local monopoly. They actually represent a very large percenteage of a small geograpical area and if so then they should not be exempted from this law. They need to be regulated as utilities need to be as they supply an essential service. Is this IPA only specialists as many IPAs are? If so then the primary care practitioners are left out.
I think that this is a fascinating thread and I have learned much reading about some of the legal issues that have ben written. Clearly, I am out of my element trying to contribute to this discussion.
But I would like to point out 2 things.
The first is that there is an unrecognized adversary out there besides the govt. and the insurance companies... the hospitals. They are working with both the govt and insurance companies to control the medical dollar. We have all seen this- consolidating doctors' practices, hospital employment models. Don't forget that the powereful hospital lobby came to Washington to seek a deal and they received it when the House bill was passed with provisions in it to pay the hospitals and have them distribute the dollar to all healthcare parties, including doctors.
We must fight this tactic with all the force that we can muster, because this is the compromise that is being discussed in Washington right now behind the scenes. There needs to be light shed on this as well.
The second point is that it would seem that we are in a catch 22. On the one hand, some discussants are pointing out that we need a system where doctors do not need to depend on the insurance industry and that organizing would be a bad idea because it would that much easier to control doctors. Conversely, others write that we should have a labor union to look out for the interests of the doctors. I think we need a representative organization like Docs 4 Patient Care
(www.docs4patientcare.org)
because nothing will change unless we are perceived to be organized and large enough to make our adversaries pay attention to what we have to say. You can blog and cerebrate and wish all that you want. You can find fault with what we are doing at D4PC. I think that we are on the right track. Until I see someone come to me and say " I've got an organization in place that can do things better than you", we will continue to develop D4PC and become the vehicle for physician representation and advocacy.
Please don't be cynical- take a leap of faith with us. You've got nothing better going on right now.
I have always said that the health insurance industry is the last, and biggest, form of organized crime in this country. They make Al Capone look like an amateur! It would seem, on the surface, that repealing the anti-trust exemption would benefit the physician in the long run (although it may hurt smaller insurance companies in the short term). Price fixing on a federal level, to the extent that they have already done with Medicare, would result in a snowball effect where all physicians followed the lead of the Mayo Clinic and opted out of all insurance payors (as I was forced to do myself 4 years ago just to keep my practice open). This will be known as "rock bottom" in our health care system. Only when you hit rock bottom can you start over with a new and innovative approach rather than trying to put band aids on a broken system (as we have been doing to date). I am not sure how things will unfold after that, but I hope that, in addition to a completely new physician reimbursement system, torte reform, and a health insurance overhaul, it will also include a revised definition of a "non-for-profit" corporation which would mandate individual income limits of all employees of such a company in order to be exempt from paying taxes. We could make a dent in our national deficit by collecting taxes on the massive amounts on money these supposedly "non-for-profit" companies make ...
Insurance is the MAFIA industry of America and is now global affecting Thrid World countries and for doctors it is the viper and nightmare of health care!
Our regional referral center is in the process of introducing this concept to physicians. In general, the doctors know nothing about this and are in a position to be blind sided.
MY medical Insurance Premiums in NY are 5 times more expensive than in Florida for BETTER policy... and FLorida has all of those retirees "dragging the state down.. and NY...well USED to have Wall street Lifting it up!
Least SERVANT both Legal , GOv and Insurance fit into Mafia .. they are the EBOLA virus of society and NEED TO BE CURED!!!!! best cure for them IS to defund them and cut off their gorging
The only thing that will save american docs and private practice is a repeal of the Sherman anti-trust act and the doctors unionizing to level the playing field. Without any organizations representing or negotiating for us we will always be at the mercy of big business the insurance companies. The AMA has and always will be useless. Dentists get paid more to fill a cavity than I get paid for surgical procedures. We need to get militant and strike if necessay
All MDs should move away from the DC area and see what government people do when they are in need of care or meds. You can't just go on vacation (liable for coverage) or strike -will be threatened and sued. Maybe they will eventually appreciate MDs, OK, they would just recognize it's in their own best interest to be able to access care - before people stop going into medicine or retire very early.
I believe that repealing McCarran-Ferguson is a good first step. But, no one should be led to believe that things will suddenly change or improve from that single legislative move. There is a complex web of state regulatory law, particular to each state that requires all kinds of things of health insurance companies. Until the consumer(patients) begin to see that health insurance should insure them for catastrophic or other high cost health expenses, and should not be a health maintenance contract, what we desire will not occur.
This will require that the states undo all of the mandates and restrictions currently governing the sale of health insurance within their borders. When the insurance industry is able to write and sell a true clearly worded basic policy, and consumers can read and understand what they are purchasing, true market based change will begin.
This is a long term goal that we should all support, not just physicians.
Our hospital-employed docs are going into an RVU system- the cardiologist says he will get $38 for an echo, hospital has reclaimed ancillaries from the PCPs, everyone is expecting a big dip in salary, and that's without the 21.5% Medicare cut!
I joined AAPS, though Docs4PC is getting a lot of free air time on talk radio. In any event we need an alternative to AMA, a true physician rep voice.
I hope for national tort reform and the removal of anti-trust exemption for insurance companies, but I fear all we may get is gridlock and a neutered Obama for the remainer of his one-term(which is not so bad).
I am scratching my head and try to see how will it change anything if anti-trust exempt law is repealed. What does anti-trust law would prohibit for Ins co? ...... that they will have to get okay from Feds before they acquire another ins co. Right. If Feds decide to approve it, they can still merge/acquire. ..... just like with Ma Bell and baby bells ATT & Cingular etc or one big pharma with another big pharma.
My guess is that ins market has already consolidated to the point that most markets are dominated by 2-3 ins co and they do work in collusion to harass docs, even if collusion is simply equal to just watching stupid docs signing contract without one single qn. Is that not a reality?
I think more imp (to encourage competition) will be to allow them to do business across state lines. Then, patients will have more competing choices. Also, de-coupling ins from employment will put pt in charge.
I don't know wether to scream or go blind. I can't believe I live in a free country! There's a lot of great info in this thread alone that could certainly be used to further our cause. Organizing is still in its infancy here. Hopefully more will wake up. Unfortunately, I think what motivates a lot of us to be doctors is what makes us difficult to organize.
I think it would be worthwhile to do a poll asking doctors if they have EVER been successful negotiating a contract vs the usual "take it or leave it" negotiation. That would demonstrate that there is no free market.
Sermo Doc 28 claims "I think it would be worthwhile to do a poll asking doctors if they have EVER been successful negotiating a contract vs the usual "take it or leave it" negotiation. That would demonstrate that there is no free market."
Really? Does the fact you can't typically negotiate the prices of food you buy at McDonalds or clothes at Nordstroms mean there is no free market?
In private practice my group had several successful negotiations with private insurance carriers. You refuse the contract and say..."we won't sign this unless you change the language in this part.....". It works, or did. They expect most docs to just sign without reading and understanding the terms. You have to be detail oriented to survive and I agree that things have gotten a lot worse.
My medical group in Northern California has had some sucess in getting reimbursements up due to the increasing scarcity of PCPS I have got some up from 85-90% of Medicare (lousy) to 115% Medicare (slightly lousy) and put in clauses defining this as current or best prior year Medicare, and removed paragraphs trying to oblige us to see Work Comp and Healthy Families patients at lower rates.
Anti trust for insurers would help us in CA - there are only 6 insurers left, they all pay remarkably similar reimbursements while we are not allowed to bargain collectively. Anthem (Blue Cross CA) has just announed 39% premium increases for PPO customers which has finally caused a firestorm of outrage in the State, and signs that the public and Assembly will fight back. I don;t see a 39% increase in reimbursements to make up for the 20% loss over the past 8 years due to inflation and minimal if any reimbursement increases in that time. BC even had the gall to ask me why their customers find it hard to get a PCP in our area - duh !
As one can see from the responses to this question, you cannot get enough physicians to agree on anything that is important to them. This makes doing something about our circumstances difficult if not impossible. When I was in medical school I thought the medical students were 'a cut above' the dental students-boy was I wrong!!! Shoulda been a dentist!
This discussion confuses me as it probably does many docs. Could someone, Sermo Doc 20, or someone else with a great knowledge of this, write a quick synopsis of the anti-trust laws. I thought it was so various businesses in the same industry couldn't get together and fix prices...the reason why Doctors are not supposed to discuss their fees with other docs. Finally, why doesn't it apply to insurance companies? or does it?
Thanks
The FTC has filed over 50 cases against doctors who attempt to collectively bargain with insurers in healthcare markets across the country. They have stepped up their efforts with the current Administration.
From the FTC...read this.
Boulder Valley Individual Practice Association, FTC File No.0510252 (proposed consent order issued December 22, 2008) (http://www.ftc.gov/os/caselist/0510252/index.shtm). The complaint charges that a multi-specialty IPA of approximately 365 physician members in the Boulder County, Colorado area unreasonably restrained competition by unreasonably restraining price and other forms of competition among its members in contracting with payers. The complaint charges that, between 2001 and 2006, BVIPA negotiated and signed agreements, on behalf of its member physicians, with approximately 17 payers, and conducted periodic renegotiations of its contracts with large payers to increase rates. During this time, BVIPA threatened payers facing rate increases with contract termination if they refused to negotiate with the physicians through the IPA, or to otherwise respond to the IPA's demands. In addition, BVIPA actively discouraged members from contracting with payers, and some payers that tried to contract with individual IPA member physicians were required to go through the IPA. Finally, although BVIPA claimed to offer payers the choice of contracting methods, in reality it did not do so, and the IPA continued to negotiate with payers on behalf of its members. The proposed consent order prohibits BVIPA from entering into or facilitating agreements between or among health care providers: (1) to negotiate on behalf of any physician with any payer; (2) to refuse, or threaten to refuse, to deal with any payer; (3) to designate the terms, conditions, or requirements upon which any physician deals, or is willing to deal, with any payer (including, but not limited to, price terms); and (4) to not deal individually with any payer, or to not deal with any payer through any arrangement other than one involving BVIPA
I included this case at random among many listed.
Now, I ask the real question. Fundamentally, how is what the BVIPA's actions any different than their local electrician's union, or the AFL-CIO, or the SEIU???
In the above complaint, substitute BVIPA with AFL-CIO, sub physicians with autoworkers, and substitute payers with automakers, and it reads like this:
AFL-CIO, FTC File No.0510252 (proposed consent order issued December 22, 2008) (http://www.ftc.gov/os/caselist/0510252/index.shtm). The complaint charges that a collection of autoworkers of approximately 365 members in the Boulder County, Colorado area unreasonably restrained competition by unreasonably restraining price and other forms of competition among its members in contracting with automakers. The complaint charges that, between 2001 and 2006, AFL-CIO negotiated and signed agreements, on behalf of its member autoworkers, with approximately 17 automakers, and conducted periodic renegotiations of its contracts with large automakers to increase rates. During this time, AFL-CIO threatened automakers facing rate increases with contract termination if they refused to negotiate with the autoworkers through the AFL-CIO, or to otherwise respond to the AFL-CIO's demands. In addition, AFL-CIO actively discouraged members from contracting with automakers, and some automakers that tried to contract with individual AFL-CIO member autoworkers were required to go through the AFL-CIO. Finally, although AFL-CIO claimed to offer automakers the choice of contracting methods, in reality it did not do so, and the AFL-CIO continued to negotiate with automakers on behalf of its members. The proposed consent order prohibits AFL-CIO from entering into or facilitating agreements between or among autoworkers: (1) to negotiate on behalf of any autoworker with any automaker; (2) to refuse, or threaten to refuse, to deal with any automaker; (3) to designate the terms, conditions, or requirements upon which any autoworker deals, or is willing to deal, with any automaker (including, but not limited to, price terms); and (4) to not deal individually with any automaker, or to not deal with any automaker through any arrangement other than one involving AFL-CIO
It reads differently, now doesn't it.
How does this difference not violate 14th Amendment equal protection?
Opted for anwer #21. "All of the above" not out of facetiousness but because each answer had, I thought, a glimmer of some relevant truism.
'Logisitically' (as it were) the answer choices could be a little better formulated & with a little less of the vulgate rhetoric.
Contentwise:
>lawdoc & rarmstrong=Cogent, as usual.
>Re-examination of anachronistic & dysfunctional anti-trust laws might make some sense, viz.:
1a. I think that MDs should have the right to unionize as MDs, given the slide to socialized medicine. I agree with Sermo Doc 6 that MD unions as such probably would eventually develop 'unionitis' over time but the possibility of an MD entity with combination of the Mouth of the Trial Lawyers & the Muscle of the Teamsters is alluring!
1b. Another way of looking at unionization of MDs might be that if MDs will continue to be forbidden to unionize as MDs then med-mal reform (cf. threads by ramstrong for specifics thereof) will be a non-negotiable article of attainment for MDs under any, all & every health care reform whatsoever.
2. Eliminating the 'ERISA' exemption for the For-Profit managed care insurers would sound like a good idea, no?
3. Personally, I think that merely 'busting-up' the insurance companies a la Teddy R circa 1900 may not help MDs or pts all that much in today's Thomas Friedman flattened-earth global economy (where everything affects everything else & everyone supposedly is regressing to a global mean).
The continued application of existing laws and regulations to situations for which they are clearly neither intended nor appropriate will only make the social and economic consequences for health care worse. The solution to the situation everyone agrees is a crisis has to begin with a logical establishment of basic premises: Everyone needs and should be offered appropriate health care, and the cost should be based upon sound, and appropriate cost-benefit analysis and business principles.
The present discussion of health care / insurance reform clearly ignores both of these fundamental issues. Borrowing from the insurance company concept, the "risk pool" has to be the entire country. The failure of any other approach is clearly visible in the recent 30-40% premium increase requested by one California insurance company because the general economy shrank the number of available subscribers, so the remaining subscribers have to pay more to insure their care. And of course the remaining subscribers will also have to continue paying their taxes for coverage of care for mandated care of the uninsured, whether to the government or in the amount added to their health care bills.
The cost of care for the country, therefore, to be fair, should be derived from actuarial calculation on a per capita basis, regardless of the sources and responsibility for these funds. To minimize the per capita cost clearly there can be no funding for the support of services and personnel not directly involved in providing necessary care. Several high quality not-for-profit health care plans, and probably Medicare, have administrative costs of less than 10% of their collected premiums. And with regard to payments for care, there must be a direct relationship between the responsible provider's per capita cost, without cost shifting between patients, and including all the expenses that are in a prudent business plan, including capital expenditures for professional education not just physical equipment, as well as the calculated value of that investment over time. One very conservative estimate suggests the minimum value of the expenditure made to obtain medical licensure and professional certification is more than $100,000 per year for the approximately 35 years of active practice life, before any compensation for the actual, daily practice of the profession.
Physicians, and other responsible health care professionals, need to be compensated appropriately for their knowledge, effort and responsibility. That isn't even being considered. The question for physicians at this time is whether an effective business model for licensed and certified practice is possible within the legal constraints that not only prevent effective physician organization (NJEM, Vol. 345, No. 15 · October 11, 2001), but even more importantly, also destroy the association between the patient's perceived value of health care services and payment for their care. Payments must be established and demanded according to appropriate and sound analysis of the true cost of providing those health care services, not arbitrary administrative decisions without regard for the true cost.
If physicians, politicians and the electorate do not get to the real issues, not special interest preservation, to develop logical, appropriate and financially sound solutions, we are all, physicians and patients, doomed. The time for angry political rhetoric, gloating, and second guessing should be over. Unfortunately, neither President Obama, with three years left to the election, nor Republican and Democratic legislators, with less than one year to the mid-term elections, get the message. The country needs change based upon accurate analysis of issues, and appropriate solutions not patches to the status quo. The status quo is what brought us to financial and functional disaster.
The FTC / DOJ most recent actions against the Roaring Fork , Colorado IPA , probably obviate the proposal that "organizing not to negotiate fees" might be a wedge to open up the discussion to realistically consider mechanisms to cover the population's health care needs, while minimizing the cost by appropriately paying only the people actually responsible for patient care, whether physicians, nurses, or ancillary health care personnel.
In essence, therefore, without dealing with the real issues, continued tinkering with the existing system of laws, regulations, and business models that are completely inappropriate for the problem, will never succeed, or provide functional, cost effective, high quality health care for the American population. The problem is it's easier for the politicians to ignore the real issues, continue dancing to the tune of the special interests, and physicians continue to pay the piper.
Sermo Doc 28 claims "I think it would be worthwhile to do a poll asking doctors if they have EVER been successful negotiating a contract vs the usual "take it or leave it" negotiation. That would demonstrate that there is no free market."
Really? Does the fact you can't typically negotiate the prices of food you buy at McDonalds or clothes at Nordstroms mean there is no free market?
dximgr, you are trying to compare two different things. You haven't signed a contract to buy food at McDonald's of clothes at Nordstroms. You could go to hundreds of other places to eat or buy clothes. As a physician, you can't control what insurance your customers (patients) have and if enough of your patients have one type of insurance, you can't afford to not be contracted with that insurance company. Then they can set (low) the price they pay you.
The root of the problem is that there is no free market when it comes to dealing with health insurance companies. If you wanted to compare the two scenarios, with McDonald's being the physician practice and customers being the insurance companies, it would be like 80% of the people in one town getting together (health insurance company holding 80% of the policies in a geographic area) and TELLING McDonald's that they would like to purchase three meals per week (health insurance companies telling us that they would like to send their patients to us for care) at McDonald's, but will only pay 50 cents on the dollar. If they won't agree to this, then NONE of the 80% of the town will ever visit McDonald's again. This is what the insurance companies are doing to us. We are FORCED into disagreeable contracts, to accept less for our services, or we are "out of network" and patients won't want to be seen by doctors who don't honor their insurance, so only a small percentage of the patients will show up at your door if you don't accept the terms of their unilateral contract. Now, if it were only 10% of the townspeople wanting the 50% discount, then McDonald's (physicians), could tell them where to stick it, but with the monopolistic powers the insurance companies have, we can't afford to lost 80% of our business by not accepting the terms of their unilateral contract. McDonald's would probably agree to the 50% discount to keep the 80% of their customers. But this would be illegal to do that to McDonald's, but it is not illegal for insurance companies to do this to us.......
Technically, we don't really have contracts with the insurance companies, because the existence of a contract requires finding the following factual elements: a) an offer; b) an acceptance of that offer which results in a meeting of the minds; c) a promise to perform; d) a valuable consideration (which can be a promise or payment in some form); e) a time or event when performance must be made (meet commitments); f) terms and conditions for performance, including fulfilling promises; g) performance.
There is no "meeting of the minds", there is no negotiating.
I truly believe that breaking up the monopolies the insurance companies hold over us is the best thing that could happen to physicians, at least what we are being paid.
A nice analysis, Dr. Lichtenstein. This gets directly to the point that I have repeatedly made here that the current proposals to reform America's health care delivery system do not address the root causes of the problems that we face and therefore will not result in any meaningful improvement. In fact, both the house and the senate bills just confound the issues, increase the bureaucracy and shift money around that in many respects isn't even available to be shifted.
The conversations that are occurring in our capitol and elsewhere have not come close to dealing with the core problems. And, the issues at hand are not right or left. Solving these problems will not be possible without truly objective analysis. Then, market forces can come into play, when and if the market is comprehensible to the participants.
It is clear that we need relief from the FTC antitust hawks. However their complaints repeatedly point out that the physician groups they've eviscerated were not clinically or financially integrated. We are yet to embrace the idea of integrated physician organizations/networks (corporate entities with a single tax ID) competitively taking responsibility for the efficient and cost effective delivery of healthcare to entire communities, in affiliation with other healthcare providers.
No one is preventing us from forming integrated healthcare delivery systems. In fact, there is a convergence of forces pointing us in that direction. Most of us, however, have not yet accepted the reality that the era of the successful solo practitioner has passed, and that its demise began when we started selling our services (cheaply and shamelessly, I might add) to government insurance agencies, health insurance companies and managed care organizations, and is now complete.
Rejecting insurance contracts and seeking to reform antitrust laws are important steps, but they do not address the clamour for universal access to healthcare, for example. We must therefore act cooperatively and elaborate a new healhcare delivery system that best serves our professional interests and the interests of our patients, and not those of insurance companies and their cronies who form government.
It is time to recognize that we must lead in the health reform process, and seize the opportunity to reclaim preeminence in the healthcare delivery system. A demoralized physician is an unsuitable guardian of the health of a community. So, act we must!
!!ORGANIZE AND CORPORATIZE!! (See previous posts.)
There are three areas of security that individuals can not provide for themselves: national defense, public safety (law enforcement) and nowadays, health care. If there is a role for government in the first two, then there should also be in the last. The government is the only thing strong enough to stand against the insurance industry. We certainly can't.
"Nobody knows....the trouble I've seen....
Nobody knows my sorrow....."
We either work together or are herded like sheep into the ovens...forget the political correctness.....this &$%^ has been going on since Medicare first called my office over 23 years ago and some 16 y/o told me I couldn't admit a patient for appendicitis because her temp wasn't over 101.5
Of course I was polite and told her she could kiss my ass..... :-)
Patient lived I have gotten older and more cynical each year....
Individually, we cannot stand against the insurance industry nor can we change or influence government to do anything. However, there is strength in numbers.
The challenge will be to determine a course and form a cohesive voice.
Sermo Doc 37, you've hit the nail on the head when you said:
"The root of the problem is that there is no free market when it comes to dealing with health insurance companies."
Take away the anti-Trust exemption for Insurance Cos. and you create free market, interstate competition along with portable Interstate policies.
It will also provide more freedom for Docs and patients to organize and negotiate for better coverage at lower cost. Forget the Govt. Where do you think Congress gets much of their cash payoffs...from Insurance Lobbyists.
In our area physicians have formed 100+ doc groups, either as cohesive single-specialty physician practices, or loosely grouped LLCs composed of smaller same-specialty practices. Using this approach these groups routinely obtain 200-300% of Medicare for private contracts. If an insurance company doesn't play ball, they simply simply drop the insurance company and unapolagetically charge patients higher out-of-network rates directly in both the inpatient and outpatient setting. And the patients pay.
In this model, the insurance companies become highly motivated to participate, and thus far have *always* eventually agreed to pay much higher rates than initially offered. In fact, this model is so successful that these physician groups are often contracted to not absorb/annex additional peripheral physician groups so these higher rates don't spread through the whole region....
Our experience is that the messenger-model IPA fails because it cannot truly collectively bargain even though it may represent hundreds of physicians. The only way to get true leverage with the big payers is to be big like them.
Interesting discussion. I am seeing it differently than some others. I believe that the issue with physicians and the insurance companies are somewhat different. The insurance companies are in the monopoly provisions of the anti-trust laws. Physicians are affected by the conspiracy aspect of the laws. They intended the antitrust laws to help protect competition.
You can only successfully negotiate a contract if you are on the same playing field or from a position of power. Typically if you are the only group providing a needed service in the area, you can get a fair contract. If there is more that one group providing the service, they will try to get you to go lower. Thus there is truth in the big group idea. That was one of the proposed benefits to a IPA. The small groups could be what they are but get the negotiation power of the big boys.
And how is the entire Medicare system not guilty of the very same trust violations, price-fixing, and anti-competition? In essence, our federal government (Medicare system) is no different than a monopoly, or even a legalized form of organized crime.
Striking would be a great option if the media would not report as they did with the last "doctor strike" that it registered the least number of patient deaths that day. "above all, do no harm" The public, for the most part, sees physicians as the trouble makers and of course the media and their "if it bleeds, it reads" mentality make the situation worse. The reality of this,we, physicians as a group, have been complacent because we have been busy with the business of medicine. In the fact, that we are all passengers in a car with the likes of Nancy pelosi and others at the wheel is of no small piece of reality. I frightens me because we need tort form at the hands of lawyers, the insurance industry out of the stock market at the hands of investors, ceos, and others making a boat load of monies, and assurances that we will get paid for our work at the hands of the biggest thief, the Federal government. Repealing antitrust legistation is NOT THE ANSWER! The government is not doing the basic things it needs to do and it will not with the leaders we have in place!
It is important to recognize that the problems we are facing are all due to Government interference in the marketplace. Therefore our long term goal should be the complete separation of medical care from the Government. There is no need for any Governmental intermediary in the doctor/patient interaction. We doctors should be allowed to trade our dedication and knowledge in a fair exchange with our patients.
Any Government interference into this process is a violation of individual rights that are guaranteed by the Declaration of Independence and the Constitution of the United States and apply to patients and doctors alike. Non-objective law such as the Anti-Trust laws are equally suspect as violations of individual rights as they are used as pretext for the ever more oppressive proliferation of Government power. In short, all these laws should be repealed!
Let us get away from all the peripheral issues listed above and divided into a dizzying list of 20 different responses and concentrate on the important. Let us again contract individually with our patients and wear the title of traders with pride and honesty.
First of all, Dan: so well written and thanks for starting this discussion.
I started to read through it all and realize I have to come back when I am calmer and can really spend time on this.
So many good ideas here. We started slowly. We never accepted HMOS and don't accept Medicaid. We are not accepting new medicare patients.
Insurers have a massive advantage over physicians in the antitrust equation. We are bound by the Sherman (passed in 1890) and Clayton (passed in 1914) Acts which were federal laws enacted to protect consumers from monopolistic behavior felt to be anticompetative. The law's intent was to prevent the restriction of trade or production in order to raise prices. These laws are regulated by the Federal trade Commission and the Department of Justice.
Specifically, The Sherman Act prohibits (a) contracts, combinations or conspiracies in restraint of trade and (b) monopolization, attempts to monopolize, and conspiracies to monopolize.
The Clayton Act prohibits (a) certain types of exclusive and conditional dealing and (b) mergers, acquisitions, and the formation of joint ventures which tend to substantially lessen competition.
The disadvantage for physicians lies with the enactment of the McCarran-Ferguson Act of 1945. This is federal law that essentially exempts the insurance industry from the aforementioned antitrust laws. It states that federal law will not supersede state law when regulating the insurance market. This is one hurdle in allowing insurers to sell policies across state lines, and is THE law that puts them at a distinct advantage in the contract negotiation process. The House bill has a provision to eliminate the exemption for the insurance industry, and one of the biggest proponents is Nancy Pelosi.
The DOJ and FTC closely monitor the conduct of physician groups, mergers and joint ventures. They believe that most group purchasing arrangements and organizations do not create antitrust problems UNLESS the arrangement creates "market power" or promotes "price fixing," and there are "safe harbors" under the guidelines. The FTC and DOJ will not challenge such an arrangement when the purchases account for less than 35% of the total sales of the goods or services in a relevant market. They will also not challenge exclusive networks whose physician participants share substantial financial risk and constitute 20% or less of the physicians in EACH specialty in any geographic market. "Sharing of substantial financial risk" can mean capitation, global case rates, withholds or other means.
The principles that must apply to manage care contracting include:
1. Financial integration, which is achieved networks providing services at a capitated rate; predetermined revenue for designated services; and most importantly, financial incentives to physicians for achieving specific cost-containment goals; risk rewarding (withholds). 2. Clinical integration. This is a predetermined plan whose purpose is to increase clinical efficiencies and reduce overall costs. 3. A plan to monitor utilization. 4. Investment of capital, human and monetary, in the infrastructure in order to realize the claimed efficiencies.
IPAs like Roaring Fork likely did not meet the criteria for inclusion in the antitrust "safe harbors." Therefore, a consent decree was ordered and the IPA essentially disbanded. Many IPAs have had the same fate (see my previous posts). Unless the McCarran-Ferguson Act is repealed, we will never have a level playing field.
I have read the previous comments and have a few thoughts...
The thing that sets physicians apart from politicians, lawyers, accountants, insurance companies, hospitals, etc. is that we primarily care about patients while they primarily care about money. We do have to pay attention to costs in order to run our practices and cover our overhead. But, the reason that we went in to medicine and what gives us purpose is patient care. We should keep our focus on that. It's why patients trust us and not them. We haven't sold our profession out for the almighty buck as they have and are trying to get us to do likewise. The doctor/patient relationship is paramount. Cut out all the middlemen and the middlemen of the middlemen. Cut out the government and cut out health insurance companies. We really don't need a union. I have never trusted any union and personally think that every union is a blood sucker to their respective industries. Doctors pride themselves in their individual abilties. Some have a good bedside manner...others don't. Some are extremely intelligent...the rest are just intelligent.. Some are excellent surgeons and prefer to be in surgery and not deal with patients while others can spend hours talking to a single patient. We are individuals and should remain so. It's why patients cry when their doctor leaves. There has to be a way for us to go back to pay for service like dentists...like lawyers...like accountants...how do we do it ? We can opt out of medicare, medicaid, and all insurance. We can charge a fee and help patients to file for their reimbursement papers. But, how do we order test, CT scans, MRIs, admit patients to hospital, renew our Massachesetts medical licence without agreeing to accept all payors ? I think that all Americans should have health care coverage. We physicians can provide this. We don't need the government or health insurance companies in order to do this. We need all physicians, pharmaceutical companies, and hospitals in order to do this. Can we talk ?
Yes, Sermo Doc 3. These are the essential ingredients of an INTEGRATED physician organization, which most doctors don't want to hear about since its efficiencies are best obtained from the use of integrated electronic medical redord and management systems by member physicians.
We need to accept and adapt to the realities of the era in which we now live if we are to retain some independence.
Sermo Doc 38, It's so nice to hear from you again. You've had many excellent ideas in the past, and I hope you'll share your thoughts with the Sermo community. OBGYNFlyer and I tried to elicit interest in a nationwide IPA in multiple prior posts. Either physicians had no interest, or they had no understanding of the value of such an organization. I'd love to revisit the concept again.
And I would like to squelch the word "unionize". It is legally impossible. Period. We need to discard this word from our physician vernacular; it is legally pointless. Stop saying "unionize", "strike" or "collective bargaining." The sooner physicians can eliminate such nonsensical ideas, the sooner we can begin to make some progress.
sewell1, you are right. Most people babble about being "unions", which doesn't work unless the physicians are all employees. These people are most singles and doubles, easily picked off from the herd. Me-thinks they deserve their 85% contract rate...
In our most recent contract negotiations, we are demanding to either be (a) not indexed to Medicare, or (b) have a rate floor set, so that if/when Medicare is cut we will minimize our losses on the private contracts. We'll see how this goes.
Sermo Doc 3, your detailed comments are greatly appreciated.
Sermo Doc 49: "The thing that sets physicians apart from politicians, lawyers, accountants, insurance companies, hospitals, etc. is that we primarily care about patients while they primarily care about money. We do have to pay attention to costs in order to run our practices and cover our overhead. But, the reason that we went in to medicine and what gives us purpose is patient care."
Well, gosh...I knew that was true about ME, but I wondered about some of YOU... :-)
I asked my brother, the lawyer, why he had gone into law, as I heard it was just about the money. "Nonsense," he said, parking his Ferrari..."I seek justice for my clients."
I then checked with my father, the retired accountant, as to his interest in juggling numbers...was it just for the money? "Of course not," he said, offended. "I devoted my energies to helping people run their companies both effectively and legally, saving them millions, and much grief." And with that he got into his Bentley and drove off.
I pitied them their lack of insight into their own motivations as I sped down the road in my Mercedes...
Thank you, Sermo Doc 3. As you know Sermo physicians are incorrigible. What we have been saying is actually working in some parts of the country, as confirmed by quiibill, but are not studied and replicated by Sermo physicians. Instead you have this constant whining, moaning and repitition of the same themes without any attempt to embrace established, workable solutions, especially by physicians in positions of leadership and influence here on Sermo. It has been puzzling to me, and most exasperating.
I continue to believe that this is an ideal forum for the sharing of meaningful information that could result in the mobilization of physicians on a wide scale. Instead, what we have seen repeatedly is that threads rapidly dry up after real solutions are introduced (this one very shortly will), and there is no mechanism for the kind of follow up, information sharing and grassroots organizing that could result in meaningful coordinated actions by physicians.
Sermo Doc 38...D4PC...the work has been going on for 8 months and the message and work is spreading. Check it out, join the group that is doing more than whining.
Least Servent do not insult the Mafia and compare them to the insurance industry. The Mafia has a code of conduct. You always know where you stand with the Mafia. You cross the line and your screwed. With insurance companies their polices and practices change by the day, hour and even minute. You never know where you stand and never get a straight answer. With the insurance industry screwing occurs on a constant basis.
Sermo Doc 5,
I'm sorry, I stand corrected. I meant physicians other than radiologists.
What I am referring to are the politicians, lawyers, accountants, etc who are trying to reform health care.
@Sermo Doc 3: I think that the U.S. v. Alston, case in Arizona involving about 50 dentists there would suggest that collective bargaining in such a large IPA or such would carry some risk. They had argued together that their reimbursement was too low, and I believe to jointly not work with an insurance payer if their terms were not met and it led to their federal persecution. Anti-trust laws unless you get an exemption like the unions did in the '30 is tricky.
Sermo Doc 3, I fear most doctors still do not understand how and how much autonomy of medicine is controlled by payment and restrictions on ability of doctors to bargain.
I think you will find more doctors focusing on malpractice.
Sermo Doc 2,
You're absolutely correct. I've been preaching antitrust law for months, and few people understand it or are interested in tackling this legal behemoth. It's at the crux of our entire payment structure, and many attempts to get around it (large physician groups attempting collective bargaining) have been squashed by the FTC/DOJ. If you assume, as I do, that the McCarran-Ferguson Act won't be repealed, then your only logical recourse to return autonomy to physicians is to:
ELIMINATE THE THIRD PARTY PAYER SYSTEM.
This would mean no further direct participation with commercial insurers or Medicare. As physicians, we should be able to contract with the patient only. Let patients purchase their health insurance and deal with their insurance company. For those of you that worry about how they will navigate myriad prior authorization and insurance formulary issues, I'll remind you that the insurance system worked relatively well until the last 10 years or so. Since then, the sociopaths that run the insurance companies have forced physicians to shoulder the administrative burdens, which has left us with less time for patients and pushed practices to the brink of extinction, just so insurance executives and shareholder can make more profit. If the consumer interacts directly with their insurer, market forces would decrease much of this egregious behavior.
If you uncouple insurance and employment and stop participating with third party payers, I'm confident medical care would improve overall. Our life would almost certainly be better, and I'm sure I'd practice better medicine if I spent more time with patients and less time on administrative bullshit.
<<most doctors still do not understand how and how much autonomy of medicine is controlled by payment and restrictions on ability of doctors to bargain.>>
this is the crux of all problems in healthcare today. Thank you Sermo Doc 2.
Sandy -- you are very smart. My salute to you.
One qn to you all thinking brains: Why dont we develop a system where every service and product is available free to anyone of any condition of monetary exchange or barter or prejudice or demand?
Sandy- I just read 920 AM post and I all I can say is that it looks like our brains are clones.
Our ability to practice medicine the way it should be requires a conflict free interaction with pt. As long as we were not required to pay attention to money and were not wasting significant time on paperwork, it was possible to have conflict free interaction. Now, these factors are threatening the very basic fabric of our system and I see young docs (including myself) deviating a lot from standards and ethics of quality medicine.
Also- 3rd party system breeds corruption, waste, fraud, abuse, misuse and overuse. It attracts greedy unethical people into our profession and that brings bad name and worse malpractice environment for all of us. Many physicians personally may be able to live with it but system as a whole has no future but collapse.
If doctors want to communicate in a zone of secrecy within a powerful organization, they should join the Masons. I would suspect that the last Masonic leaders were Gerald Ford and George Bush I. It was the best I could come up with since specific Masonic groups could promote the interest of doctors without violating anti-trust regulations as I doubt the government would take on the Masons. The specific lodge could limit itself to doctors, once it is organized. One may belong to more than one lodge. People like George Washington, Ben Franklin, Andrew Jackson etc. were Masons. I, however, am not a Mason, but would join if doctors could have their own lodges.
Until the 1950's it was UNETHICAL per AMA for docs to be paid by any profit making entity other than patient. FTC said this was monopolistic, and AMA changed it's ethics.
Simply agreeing that we would not accept payment from anyone other than patient would fix the problem 100% IMHO. However, it would be illegal unless laws could be changed.
It is clear that if Docs are paid by someone other than patient there is a conflict of interest. Or do you think HMO rules are always in patient's best interest?
Sermo Doc 53: "Or do you think HMO rules are always in patient's best interest?"
No, of course not. Yet I think it much more likely that HMO rules are most closely alligned with the patient's interest than, say, Medicare rules...You can choose another HMO. You're basically stuck with Medicare.
Nothing gets done in Washington without a political reason or some disaster. You need a rallying cry. Remember Hurricane Katrina? If you want real change in how the folks in DC do, you have to go about it in certain ways. Those docs that got arrested in Baltimore at the Republican meeting with the President understood I think. Even if you did not like what they said they knew: TV is your friend. Lobbying helps too. Maybe Sermo physicians or the AMA can use the DC healthcare lobbyists to hep back antitrust reform. Those K street types might be too expensive though! But docs could really use the ability to establish a collective bargaining units. Insurance companies have the advantage now as rules do not allow self-employed physicians to engage in collective bargaining with health plans. Maybe Former politicians like Mr. Daschle or Mr. Gephardt can use their political connections to have the House Judiciary Committee take up the cause. As I understand it that committee in the House has jurisdiction in the area of antitrust legislation. Physicians need a Congressional hearing! And remember: Marketing the idea of physician led reform helps too! So stop typing and actually talk to your medical colleagues and patients folks!
I agree totally. do away with third party payors. in fact I have been doing it for years , as have many Psychiatrists, probably because the reimbursement rate for Psychiatrists had been so low, anyway. I charge the patient, the patient pays me, they send the bill to the insurance company for reimbursement. Is that what people envision when they talk about getting rid of third party payors, or is it something else? By the way, interestingly enough, none of us in my town have ever discussed how much we charge with each other for fear of the antitrust laws. But we have discussed leaving insurance panels. That soon becomes public record anyway.
<I charge the patient, the patient pays me, they send the bill to the insurance company for reimbursement. >
You are 100% correct. In fact, the only sane physicians seem to be the psychiatrists who have been doing this for years.
Discussing non-participation with third party payers is NOT an antitrust violation. Discussing fees is.
This is pretty simple really. We must ALL say no to the third party payer system. The dynamics will change overnight, and your life will be infinitely more rewarding.
The Roaring Fork IPA spent more than $500,000 "defending" itself from the FTC. After the war chest was spent down it reluctantly signed the consent decree. The Roaring Fork IPA, like the Boulder IPA, has not disbanded. The main beef that the FTC had with the IPA is that it rejected all RBRVS contracts. In retrospective evaluation, if you look at the declining RBRVS rates this was a good business decision. The Roaring Fork IPA's members individually would have voted these contracts down, therefore, why bother messengering them? The Roaring Fork IPA never forbid contracting around the IPA itself. In fact nearly all physicians have contracts that were obtained outside of the IPA. How is that price fixing? In the consent decree, the Roaring Fork IPA will simply have to messenger RBRVS contracts. FYI, RBRVS means Resource-Based Relative Value Scale (RBRVS). Resource-Based Relative Value Scale (RBRVS) is a schema used to determine how much money medical providers should be paid. It is currently used by Medicare in the United States and by nearly all Health maintenance organizations (HMOs). RBRVS often decreases the monitary value of services based on a fixed pot of money that the Goverment has budgeted. As in 1989 a law was passed to rein in the escalating Medicare costs. This law in effect made mandated that Medicare spending be budget neutral. Therfore, RBRVS redistributes Medicare dollars and never increases Medicare dollars. In that RBRVS often decreases payments for services, physicians are at financial risk if they sign. The Roaring Fork IPA will messenger all contracts but historically poor contracts are rejected through a member by member vote. There has never been collective voting in this IPA. In that insurance companies financially benefit in having a "Network" of contracted physicians, they will have to present to the IPA or individual physicians with Injenex based fee scheduled contracts. Furthermore, Cost of Living Adjustments (COLA) will be eliminated from future contracts. All that means is that contracts will have to be renegotiated on a annual basis in stead of an automatic increase. More work for the IPA AND the insurance companies. The Roaring Fork IPA has always been about educating physicians about an extremely complex payment system.
So very depressing. For the first time, I am truly tempted to drop participation in all insurances: medicare, medicaid, PPOs, etc. This would lead to my losing my hospital privileges as our bylaws mandate that we have to participate with medicare, but giving up hospital/ER call and the politics would only enhance my quality of life - considerably.
If I had my way, I think I'd like to build a home downtown in which the front of the downstairs was my office space, and the rest would house my family and myself. In this way, I could offer extended hours availability, and utilize my family to assist me rather than having to hire outside employees. I'd offer labs, Xrays, and EKG, and everything would have a price listed on a menu. I'd accept cash, checks and cards, and give a cash discount. I'd probably keep my LPN because she is good and can help speed me up considerably when we are busy. I would NOT buy the expensive EMR and would go back to handwritten paper charts - with three or four office visits listed on one page - listing only the info I need - not having to worry about documentation for audits or medicolegal protection. I'd post a sign stating that I don't have medical malpractice insurance, and would go bare (and of course proterct my assets).
Anyone who wants it can have an invoice and can file it with their own insurer if they want to, but we aren't going to file, and likewise, we aren't going to do prior authorizations for anything. If patients want that, they can do to their PPO assigned doctor, because I simply will not have the manpower to play that game any longer.
Doesn't that sound like nirvana? I wonder how many less patients I could see in a day and still make at least as much as I am taking home now.
I'm just daydreaming at this point, but it could actually happen.
Maybe go back to school a be a doggie orthopod. They get $3000 for a hip replacement cash on the barrel head. I'd take wagging tails and sloppy kisses over unappreciative patients and continuing government harrassment anyday. Hmmm a doggie ortho, rehab, pain clinic.
Thought I'd note, that back in 2000, there was a bill from Tom Campbell and John Conyers that would have provided antitrust exemption to physicians to negotiate with managed care organizations. It passed the House of Representatives with bipartisan support, but died in the Senate. www.nytimes.com
As a side note, Tom Campbell is now running in the Republican primary for Senate to face Barbara Boxer. Wonder if he'd be willing to back the same bill now?
this is done all the time. congressmen/women will vote for something their party is against (or the public wants) knowing that it won't pass in the Senate. they do the same thing with committee votes.
From Associated Press
February 12, 2010 11:40 PM EST
TRENTON, N.J. (AP) — "Consumers in at least four states who buy their own health insurance are getting hit with premium increases of 15 percent or more — and people in other states could see the same thing.
Anthem Blue Cross, a subsidiary of WellPoint Inc., has been under fire for a week from regulators and politicians for notifying some of its 800,000 individual policyholders in California that it plans to raise rates by up to 39 percent March 1.
The Anthem Blue Cross plan in Maine is asking for increases of about 23 percent this year for some individual policyholders. Last year, they raised rates up to 32 percent."
my.earthlink.net ******************************************************************************************
When and how does this end?
Sermo Doc 3-In my neck of the woods (NYC) the state law says that sedation done in the office must be done by one experienced in airway management. More and more anesthesiologists become hired by other practitioners to provide that service in practitioners office. We now receive salary and questionable billing practices abound.
My point is that I am interested in your IPA and I believe many office anesthesiologists in the northeast where we have our largest numbers, would be interested as well. I am talking about busy practices, wealthy, sophisticated demographics and misunderstood safe harbors.
Interesting that 1/4 of the total spent was by the AMA themselves....suposidly representing physician and physician interest....MY AS____ they are representing us....
Who stands up for both PCP's and the specialist? The AMA? I think not! An organization like docs4pc may be the answer. I wonder how a physician's union would be received? On one hand I'm sure they would try to use antitrust laws against this. Remember BO is the union's president, he is pushing for the expansion of unions. This would expose him for the two faced politician he is . Imagine allowing the nurses to unionize but the physicians- well that's anti- trust.
Yes, the McCarran-Ferguson act must be altered or repealed. The Republicans will be forced into advocating this.
ERISA is another abomination that allows all employment based insurance to be deemed not insurance, and governed by federal contract law. Practical implications of this is that plans can jaw bone doctors financially as much as they want, and when the doctor compromises judgment, the doctor bears ALL the malpractice liability
BUT IT GETS EVEN WORSE
The federal anitrust laws in such a way that they stop wherever a STATE regulates.
The states could each authorize collective bargaining by doctors. In the late 90's, Texas, New Jersey, and Washington DC all passed such laws. The DC law was invalidated by the control board that governed DC at the time (Alice Rivlin, Clinton scum appointee)
Texas and New Jersey laws all later watered down and revoked, in Texas that great friend of medicine, Geo W Bush, retard extraordinaire saw to it that the law was never actually enforced,
AMA was never strong on board.
The irony, is that any law passed in DC must be ratified by Congress which never invalidates a law from DC that doesn't involve abortion, so AMA could have tricked Congress into voting for collective bargaining . It didn't.
I have been preaching antitrust issues for as long as I have been a member of Sermo. I think physicians have little understanding of the implications of this century-old legislation, and have even less understanding of the applicability to their practices.
The McCarran-Ferguson Act created insulation for the insurance industry that they have exploited to our detriment. Congress—as usual, bought off by Big Business—could care less about "leveling the playing field" between insurers and physicians. Moreover, the insurance industry and the Democrats (remember the Obama tonsillectomy / amputation gaffe?) have vilified physicians in order to garner support for the reduction of our salaries.
The Roaring Fork decision is small peanuts (http://www.ftc.gov/opa/2010/02/roaringfork.shtm). We need to look at the vast oppression exerted on us by the FTC and DOJ. Look at this post to get a better understanding of antitrust law:
md.sermo.com
And look here to see how antitrust law unfairly discriminates against physicians:
ftc.gov
We physicians need to get educated, and must get a grasp of the immense legal hurdles we face if we have any hope of surviving.
The insurance industry is not the enemy, only one of several.
Doctors will be exploited so long as doctors are willing to be exploited. We have an absolute constitutional guarantee to petition government, and at the state level we can get our states to authorize collective bargaining. That is the start for us.
It starts with a Supreme Court decision called Parker v Brown and moves through several others.
Real legal advice would be how to use that series of cases.
Doctors have to stop getting their legal advice form the defense bar which is just one more exploiter of doctors.
Lobby at the state level using Parker v Brown for state authorization to bargain collectively and then lean on the Republicans to challenge Obama on repeal of the McF act.
That should go a long way towards leveling the playing field.
Dan Jones, MD www.JonesPlan.BlogSpot.com
Also of interest are the claims, both fundamentally wrong and yet widely believed, about Standard Oil and their policy of "predatory pricing" that led to the Sherman Act being used to break up Rockerfeller's company. In fact the original claims in a book by Ida Tarbell
(The History of the Standard Oil Company (New York: Peter Smith, 1950). Tarbell's brother, William, was treasurer of Pure Oil Company, a direct competitor) were thoroughly demolished on both economic and historical grounds by economist John McGee
("Predatory Price Cutting: The Standard Oil (N.J.) Case," Journal of Law and Economics 1 (April 1958): 13769.) This material is well summarized at: www.cato.org
If you have no contracts there can be no anti-competitive behavior at that level. The FTC could still presumably go after small groups of local physicians if they felt they could prove price collusion among competitors, but the chance of that collusion occurring is extraordinarily small, and proving it would be next to impossible.
As an interesting aside, it is accepted as typical and even standard behavior that if an airline changes its rates for a given route, its competitors will very quickly (within days) change their rates to match, and even publicize the event if it happens to be a rate cut. But airlines are regulated under different legislation than is medicine.
What really scares the FTC, though, and every other govt entity involved in physician regulation, is the notion of regulating 800,000 individual practitioners. There was a quote from a govt official in the Wall Street Journal several months ago to the effect that the government is trying to force physicians into organizations (i.e. to become employees) because it is much simpler to regulate a few thousand organizations than 800,000 individuals. I'm sorry that I can't reproduce the actual quote here, but the fact is that the government wants to regulate us, is trying to herd us into employee status in order to do so and has, at least on occasion, admitted to this.
A physicians union is a poor alternative to independent physicians, simply because over time it would almost certainly do as the AMA has done, and as most trade unions do now, and put its own interests ahead of that of its membership.
Eliminating all insurer contracts - private, Medicare, Medicaid, etc, is a difficult move for some physicians, most notably those in large hospital-employed groups. For them, they probably don't have the authority to unilaterally do so without the hospital's approval, which will be difficult, if not impossible to obtain. So they have to consider leaving their current job in addition to refusing contracts. For solo and small group PCPs, though, the market demand for their services is such that it makes no sense for them not to do it, as of yesterday.
While the earliest adopters in a given locale may find a temporary drop in their practice volume, there are many examples on Sermo and elsewhere demonstrating that the practice recovers, and were the majority of PCPs in an area to follow suit, the market would immediately have to rebalance itself anyway. The fear of making the leap is the biggest enemy in medicine today, even more so than insurers or the government. It is contracts, and only contracts, that give the insurers and the government their power over us.
And if the concern surrounds the fact that the health care sector encompasses such a large sector of the economy, is there similar concern for the 150,000 dentists, 75% of whom are solo practitioners?
What about the 150,000 physical therapists?
And if the concern surrounds the fact that the health care sector encompasses such a large sector of the economy, is there similar concern for the 150,000 dentists, 75% of whom are solo practitioners?"
I don't think it's the fact healthcare encompasses such a large sector of the economy, but that it's a portion of the economy paid for, about 50%, by the government. Attorneys and CPAs don't get paid by the government in the same way.
On the other hand, there is no way the public will countenance an antitrust exemption for physicians. So you just can't do what roaring fork did. The percentage of physicians it involves is irrelevant.
What we really need is the conversion of big health insurers to nonprofits, like they do in the Swiss system. The physicians are left alone, and the insurers compete on supplemental plans. Given that, I personally could live with no antitrust exemption.
Part 2 - Tort reform.
With Roaring Fork, it's naked control, a distortion of any conceivable sense of legislative intent, and worth fighting. I'll say again what I've oft said: it's critical that docs and patients fight together, rather than adopt positions which our opponents would use to turn us against each other. If the goal is cost-effective care, better access and, in general, better patient care, we'll win. If it's merely who has the power, we won't. Don't mistake what I'm saying: these aren't mutually exclusive. But if docs are seen fighting only for themselves--and that's how our opponents will portray us, every chance they get--we'll lose.
I want ONE example of this. Just one. I GUARANTEE you the is not one case in the entire country where insurance industry agreements with an IPA have lowered the cost of insurance.
My eyes are bleeding. I need to go apply pressure.
But I would like to point out 2 things.
The first is that there is an unrecognized adversary out there besides the govt. and the insurance companies... the hospitals. They are working with both the govt and insurance companies to control the medical dollar. We have all seen this- consolidating doctors' practices, hospital employment models. Don't forget that the powereful hospital lobby came to Washington to seek a deal and they received it when the House bill was passed with provisions in it to pay the hospitals and have them distribute the dollar to all healthcare parties, including doctors.
We must fight this tactic with all the force that we can muster, because this is the compromise that is being discussed in Washington right now behind the scenes. There needs to be light shed on this as well.
The second point is that it would seem that we are in a catch 22. On the one hand, some discussants are pointing out that we need a system where doctors do not need to depend on the insurance industry and that organizing would be a bad idea because it would that much easier to control doctors. Conversely, others write that we should have a labor union to look out for the interests of the doctors. I think we need a representative organization like Docs 4 Patient Care
(www.docs4patientcare.org)
because nothing will change unless we are perceived to be organized and large enough to make our adversaries pay attention to what we have to say. You can blog and cerebrate and wish all that you want. You can find fault with what we are doing at D4PC. I think that we are on the right track. Until I see someone come to me and say " I've got an organization in place that can do things better than you", we will continue to develop D4PC and become the vehicle for physician representation and advocacy.
Please don't be cynical- take a leap of faith with us. You've got nothing better going on right now.
Hal
with luck, it will squeak through the senate
md.sermo.com
Our regional referral center is in the process of introducing this concept to physicians. In general, the doctors know nothing about this and are in a position to be blind sided.
Next on the agenda is Big Tort Reform.
If we get the above, we can concentrate on the other HCR issues.
www.chqpr.org
This will require that the states undo all of the mandates and restrictions currently governing the sale of health insurance within their borders. When the insurance industry is able to write and sell a true clearly worded basic policy, and consumers can read and understand what they are purchasing, true market based change will begin.
This is a long term goal that we should all support, not just physicians.
I joined AAPS, though Docs4PC is getting a lot of free air time on talk radio. In any event we need an alternative to AMA, a true physician rep voice.
I hope for national tort reform and the removal of anti-trust exemption for insurance companies, but I fear all we may get is gridlock and a neutered Obama for the remainer of his one-term(which is not so bad).
What does anti-trust law would prohibit for Ins co? ...... that they will have to get okay from Feds before they acquire another ins co. Right. If Feds decide to approve it, they can still merge/acquire. ..... just like with Ma Bell and baby bells ATT & Cingular etc or one big pharma with another big pharma.
My guess is that ins market has already consolidated to the point that most markets are dominated by 2-3 ins co and they do work in collusion to harass docs, even if collusion is simply equal to just watching stupid docs signing contract without one single qn. Is that not a reality?
I think more imp (to encourage competition) will be to allow them to do business across state lines. Then, patients will have more competing choices. Also, de-coupling ins from employment will put pt in charge.
law.jrank.org
And exempted them from the Sherman anti-trust act. It is a roadblock to selling health insurance across state lines.
Really? Does the fact you can't typically negotiate the prices of food you buy at McDonalds or clothes at Nordstroms mean there is no free market?
Anti trust for insurers would help us in CA - there are only 6 insurers left, they all pay remarkably similar reimbursements while we are not allowed to bargain collectively. Anthem (Blue Cross CA) has just announed 39% premium increases for PPO customers which has finally caused a firestorm of outrage in the State, and signs that the public and Assembly will fight back. I don;t see a 39% increase in reimbursements to make up for the 20% loss over the past 8 years due to inflation and minimal if any reimbursement increases in that time. BC even had the gall to ask me why their customers find it hard to get a PCP in our area - duh !
As one can see from the responses to this question, you cannot get enough physicians to agree on anything that is important to them. This makes doing something about our circumstances difficult if not impossible. When I was in medical school I thought the medical students were 'a cut above' the dental students-boy was I wrong!!! Shoulda been a dentist!
Thanks
From the FTC...read this.
Boulder Valley Individual Practice Association, FTC File No.0510252 (proposed
consent order issued December 22, 2008)
(http://www.ftc.gov/os/caselist/0510252/index.shtm). The complaint charges that a
multi-specialty IPA of approximately 365 physician members in the Boulder County,
Colorado area unreasonably restrained competition by unreasonably restraining price and other forms of competition among its members in contracting with payers. The
complaint charges that, between 2001 and 2006, BVIPA negotiated and signed
agreements, on behalf of its member physicians, with approximately 17 payers, and
conducted periodic renegotiations of its contracts with large payers to increase rates.
During this time, BVIPA threatened payers facing rate increases with contract
termination if they refused to negotiate with the physicians through the IPA, or to
otherwise respond to the IPA's demands. In addition, BVIPA actively discouraged
members from contracting with payers, and some payers that tried to contract with
individual IPA member physicians were required to go through the IPA. Finally,
although BVIPA claimed to offer payers the choice of contracting methods, in reality it
did not do so, and the IPA continued to negotiate with payers on behalf of its members.
The proposed consent order prohibits BVIPA from entering into or facilitating
agreements between or among health care providers: (1) to negotiate on behalf of any
physician with any payer; (2) to refuse, or threaten to refuse, to deal with any payer; (3)
to designate the terms, conditions, or requirements upon which any physician deals, or is
willing to deal, with any payer (including, but not limited to, price terms); and (4) to not
deal individually with any payer, or to not deal with any payer through any arrangement
other than one involving BVIPA
I included this case at random among many listed.
Now, I ask the real question. Fundamentally, how is what the BVIPA's actions any different than their local electrician's union, or the AFL-CIO, or the SEIU???
In the above complaint, substitute BVIPA with AFL-CIO, sub physicians with autoworkers, and substitute payers with automakers, and it reads like this:
AFL-CIO, FTC File No.0510252 (proposed
consent order issued December 22, 2008)
(http://www.ftc.gov/os/caselist/0510252/index.shtm). The complaint charges that a
collection of autoworkers of approximately 365 members in the Boulder County,
Colorado area unreasonably restrained competition by unreasonably restraining price and other forms of competition among its members in contracting with automakers. The complaint charges that, between 2001 and 2006, AFL-CIO negotiated and signed
agreements, on behalf of its member autoworkers, with approximately 17 automakers, and conducted periodic renegotiations of its contracts with large automakers to increase rates. During this time, AFL-CIO threatened automakers facing rate increases with contract termination if they refused to negotiate with the autoworkers through the AFL-CIO, or to otherwise respond to the AFL-CIO's demands. In addition, AFL-CIO actively discouraged members from contracting with automakers, and some automakers that tried to contract with individual AFL-CIO member autoworkers were required to go through the AFL-CIO. Finally, although AFL-CIO claimed to offer automakers the choice of contracting methods, in reality it did not do so, and the AFL-CIO continued to negotiate with automakers on behalf of its members. The proposed consent order prohibits AFL-CIO from entering into or facilitating agreements between or among autoworkers: (1) to negotiate on behalf of any autoworker with any automaker; (2) to refuse, or threaten to refuse, to deal with any automaker; (3)
to designate the terms, conditions, or requirements upon which any autoworker deals, or is willing to deal, with any automaker (including, but not limited to, price terms); and (4) to not deal individually with any automaker, or to not deal with any automaker through any arrangement other than one involving AFL-CIO
It reads differently, now doesn't it.
How does this difference not violate 14th Amendment equal protection?
'Logisitically' (as it were) the answer choices could be a little better formulated & with a little less of the vulgate rhetoric.
Contentwise:
>lawdoc & rarmstrong=Cogent, as usual.
>Re-examination of anachronistic & dysfunctional anti-trust laws might make some sense, viz.:
1a. I think that MDs should have the right to unionize as MDs, given the slide to socialized medicine. I agree with Sermo Doc 6 that MD unions as such probably would eventually develop 'unionitis' over time but the possibility of an MD entity with combination of the Mouth of the Trial Lawyers & the Muscle of the Teamsters is alluring!
1b. Another way of looking at unionization of MDs might be that if MDs will continue to be forbidden to unionize as MDs then med-mal reform (cf. threads by ramstrong for specifics thereof) will be a non-negotiable article of attainment for MDs under any, all & every health care reform whatsoever.
2. Eliminating the 'ERISA' exemption for the For-Profit managed care insurers would sound like a good idea, no?
3. Personally, I think that merely 'busting-up' the insurance companies a la Teddy R circa 1900 may not help MDs or pts all that much in today's Thomas Friedman flattened-earth global economy (where everything affects everything else & everyone supposedly is regressing to a global mean).
The present discussion of health care / insurance reform clearly ignores both of these fundamental issues. Borrowing from the insurance company concept, the "risk pool" has to be the entire country. The failure of any other approach is clearly visible in the recent 30-40% premium increase requested by one California insurance company because the general economy shrank the number of available subscribers, so the remaining subscribers have to pay more to insure their care. And of course the remaining subscribers will also have to continue paying their taxes for coverage of care for mandated care of the uninsured, whether to the government or in the amount added to their health care bills.
The cost of care for the country, therefore, to be fair, should be derived from actuarial calculation on a per capita basis, regardless of the sources and responsibility for these funds. To minimize the per capita cost clearly there can be no funding for the support of services and personnel not directly involved in providing necessary care. Several high quality not-for-profit health care plans, and probably Medicare, have administrative costs of less than 10% of their collected premiums.
And with regard to payments for care, there must be a direct relationship between the responsible provider's per capita cost, without cost shifting between patients, and including all the expenses that are in a prudent business plan, including capital expenditures for professional education not just physical equipment, as well as the calculated value of that investment over time. One very conservative estimate suggests the minimum value of the expenditure made to obtain medical licensure and professional certification is more than $100,000 per year for the approximately 35 years of active practice life, before any compensation for the actual, daily practice of the profession.
Physicians, and other responsible health care professionals, need to be compensated appropriately for their knowledge, effort and responsibility. That isn't even being considered. The question for physicians at this time is whether an effective business model for licensed and certified practice is possible within the legal constraints that not only prevent effective physician organization (NJEM, Vol. 345, No. 15 · October 11, 2001), but even more importantly, also destroy the association between the patient's perceived value of health care services and payment for their care. Payments must be established and demanded according to appropriate and sound analysis of the true cost of providing those health care services, not arbitrary administrative decisions without regard for the true cost.
If physicians, politicians and the electorate do not get to the real issues, not special interest preservation, to develop logical, appropriate and financially sound solutions, we are all, physicians and patients, doomed. The time for angry political rhetoric, gloating, and second guessing should be over. Unfortunately, neither President Obama, with three years left to the election, nor Republican and Democratic legislators, with less than one year to the mid-term elections, get the message. The country needs change based upon accurate analysis of issues, and appropriate solutions not patches to the status quo. The status quo is what brought us to financial and functional disaster.
The FTC / DOJ most recent actions against the Roaring Fork , Colorado IPA , probably obviate the proposal that "organizing not to negotiate fees" might be a wedge to open up the discussion to realistically consider mechanisms to cover the population's health care needs, while minimizing the cost by appropriately paying only the people actually responsible for patient care, whether physicians, nurses, or ancillary health care personnel.
In essence, therefore, without dealing with the real issues, continued tinkering with the existing system of laws, regulations, and business models that are completely inappropriate for the problem, will never succeed, or provide functional, cost effective, high quality health care for the American population. The problem is it's easier for the politicians to ignore the real issues, continue dancing to the tune of the special interests, and physicians continue to pay the piper.
Eric S. Lichtenstein, MD, FACP, FACE
Sermo Doc 28 claims "I think it would be worthwhile to do a poll asking doctors if they have EVER been successful negotiating a contract vs the usual "take it or leave it" negotiation. That would demonstrate that there is no free market."
Really? Does the fact you can't typically negotiate the prices of food you buy at McDonalds or clothes at Nordstroms mean there is no free market?
dximgr, you are trying to compare two different things. You haven't signed a contract to buy food at McDonald's of clothes at Nordstroms. You could go to hundreds of other places to eat or buy clothes. As a physician, you can't control what insurance your customers (patients) have and if enough of your patients have one type of insurance, you can't afford to not be contracted with that insurance company. Then they can set (low) the price they pay you.
The root of the problem is that there is no free market when it comes to dealing with health insurance companies. If you wanted to compare the two scenarios, with McDonald's being the physician practice and customers being the insurance companies, it would be like 80% of the people in one town getting together (health insurance company holding 80% of the policies in a geographic area) and TELLING McDonald's that they would like to purchase three meals per week (health insurance companies telling us that they would like to send their patients to us for care) at McDonald's, but will only pay 50 cents on the dollar. If they won't agree to this, then NONE of the 80% of the town will ever visit McDonald's again. This is what the insurance companies are doing to us. We are FORCED into disagreeable contracts, to accept less for our services, or we are "out of network" and patients won't want to be seen by doctors who don't honor their insurance, so only a small percentage of the patients will show up at your door if you don't accept the terms of their unilateral contract. Now, if it were only 10% of the townspeople wanting the 50% discount, then McDonald's (physicians), could tell them where to stick it, but with the monopolistic powers the insurance companies have, we can't afford to lost 80% of our business by not accepting the terms of their unilateral contract. McDonald's would probably agree to the 50% discount to keep the 80% of their customers. But this would be illegal to do that to McDonald's, but it is not illegal for insurance companies to do this to us.......
Technically, we don't really have contracts with the insurance companies, because the existence of a contract requires finding the following factual elements: a) an offer; b) an acceptance of that offer which results in a meeting of the minds; c) a promise to perform; d) a valuable consideration (which can be a promise or payment in some form); e) a time or event when performance must be made (meet commitments); f) terms and conditions for performance, including fulfilling promises; g) performance.
There is no "meeting of the minds", there is no negotiating.
I truly believe that breaking up the monopolies the insurance companies hold over us is the best thing that could happen to physicians, at least what we are being paid.
The conversations that are occurring in our capitol and elsewhere have not come close to dealing with the core problems. And, the issues at hand are not right or left. Solving these problems will not be possible without truly objective analysis. Then, market forces can come into play, when and if the market is comprehensible to the participants.
No one is preventing us from forming integrated healthcare delivery systems. In fact, there is a convergence of forces pointing us in that direction. Most of us, however, have not yet accepted the reality that the era of the successful solo practitioner has passed, and that its demise began when we started selling our services (cheaply and shamelessly, I might add) to government insurance agencies, health insurance companies and managed care organizations, and is now complete.
Rejecting insurance contracts and seeking to reform antitrust laws are important steps, but they do not address the clamour for universal access to healthcare, for example. We must therefore act cooperatively and elaborate a new healhcare delivery system that best serves our professional interests and the interests of our patients, and not those of insurance companies and their cronies who form government.
It is time to recognize that we must lead in the health reform process, and seize the opportunity to reclaim preeminence in the healthcare delivery system. A demoralized physician is an unsuitable guardian of the health of a community. So, act we must!
!!ORGANIZE AND CORPORATIZE!! (See previous posts.)
Nobody knows my sorrow....."
We either work together or are herded like sheep into the ovens...forget the political correctness.....this &$%^ has been going on since Medicare first called my office over 23 years ago and some 16 y/o told me I couldn't admit a patient for appendicitis because her temp wasn't over 101.5
Of course I was polite and told her she could kiss my ass..... :-)
Patient lived I have gotten older and more cynical each year....
P.S Have a nice day :-) ))))))))
The challenge will be to determine a course and form a cohesive voice.
"The root of the problem is that there is no free market when it comes to dealing with health insurance companies."
Take away the anti-Trust exemption for Insurance Cos. and you create free market, interstate competition along with portable Interstate policies.
It will also provide more freedom for Docs and patients to organize and negotiate for better coverage at lower cost. Forget the Govt. Where do you think Congress gets much of their cash payoffs...from Insurance Lobbyists.
In our area physicians have formed 100+ doc groups, either as cohesive single-specialty physician practices, or loosely grouped LLCs composed of smaller same-specialty practices. Using this approach these groups routinely obtain 200-300% of Medicare for private contracts. If an insurance company doesn't play ball, they simply simply drop the insurance company and unapolagetically charge patients higher out-of-network rates directly in both the inpatient and outpatient setting. And the patients pay.
In this model, the insurance companies become highly motivated to participate, and thus far have *always* eventually agreed to pay much higher rates than initially offered. In fact, this model is so successful that these physician groups are often contracted to not absorb/annex additional peripheral physician groups so these higher rates don't spread through the whole region....
Our experience is that the messenger-model IPA fails because it cannot truly collectively bargain even though it may represent hundreds of physicians. The only way to get true leverage with the big payers is to be big like them.
The solution is to drop all government insurance.
Any Government interference into this process is a violation of individual rights that are guaranteed by the Declaration of Independence and the Constitution of the United States and apply to patients and doctors alike. Non-objective law such as the Anti-Trust laws are equally suspect as violations of individual rights as they are used as pretext for the ever more oppressive proliferation of Government power. In short, all these laws should be repealed!
Let us get away from all the peripheral issues listed above and divided into a dizzying list of 20 different responses and concentrate on the important. Let us again contract individually with our patients and wear the title of traders with pride and honesty.
For greater detail visit www.aynrandcenter.org
I started to read through it all and realize I have to come back when I am calmer and can really spend time on this.
So many good ideas here. We started slowly. We never accepted HMOS and don't accept Medicaid. We are not accepting new medicare patients.
Insurers have a massive advantage over physicians in the antitrust equation. We are bound by the Sherman (passed in 1890) and Clayton (passed in 1914) Acts which were federal laws enacted to protect consumers from monopolistic behavior felt to be anticompetative. The law's intent was to prevent the restriction of trade or production in order to raise prices. These laws are regulated by the Federal trade Commission and the Department of Justice.
Specifically, The Sherman Act prohibits (a) contracts, combinations or conspiracies in restraint of trade and (b) monopolization, attempts to monopolize, and conspiracies to monopolize.
The Clayton Act prohibits (a) certain types of exclusive and conditional dealing and (b) mergers, acquisitions, and the formation of joint ventures which tend to substantially lessen competition.
The disadvantage for physicians lies with the enactment of the McCarran-Ferguson Act of 1945. This is federal law that essentially exempts the insurance industry from the aforementioned antitrust laws. It states that federal law will not supersede state law when regulating the insurance market. This is one hurdle in allowing insurers to sell policies across state lines, and is THE law that puts them at a distinct advantage in the contract negotiation process. The House bill has a provision to eliminate the exemption for the insurance industry, and one of the biggest proponents is Nancy Pelosi.
The DOJ and FTC closely monitor the conduct of physician groups, mergers and joint ventures. They believe that most group purchasing arrangements and organizations do not create antitrust problems UNLESS the arrangement creates "market power" or promotes "price fixing," and there are "safe harbors" under the guidelines. The FTC and DOJ will not challenge such an arrangement when the purchases account for less than 35% of the total sales of the goods or services in a relevant market. They will also not challenge exclusive networks whose physician participants share substantial financial risk and constitute 20% or less of the physicians in EACH specialty in any geographic market. "Sharing of substantial financial risk" can mean capitation, global case rates, withholds or other means.
The principles that must apply to manage care contracting include:
1. Financial integration, which is achieved networks providing services at a capitated rate; predetermined revenue for designated services; and most importantly, financial incentives to physicians for achieving specific cost-containment goals; risk rewarding (withholds).
2. Clinical integration. This is a predetermined plan whose purpose is to increase clinical efficiencies and reduce overall costs.
3. A plan to monitor utilization.
4. Investment of capital, human and monetary, in the infrastructure in order to realize the claimed efficiencies.
IPAs like Roaring Fork likely did not meet the criteria for inclusion in the antitrust "safe harbors." Therefore, a consent decree was ordered and the IPA essentially disbanded. Many IPAs have had the same fate (see my previous posts). Unless the McCarran-Ferguson Act is repealed, we will never have a level playing field.
I hope this information was helpful.
The thing that sets physicians apart from politicians, lawyers, accountants, insurance companies, hospitals, etc. is that we primarily care about patients while they primarily care about money. We do have to pay attention to costs in order to run our practices and cover our overhead. But, the reason that we went in to medicine and what gives us purpose is patient care. We should keep our focus on that. It's why patients trust us and not them. We haven't sold our profession out for the almighty buck as they have and are trying to get us to do likewise. The doctor/patient relationship is paramount. Cut out all the middlemen and the middlemen of the middlemen. Cut out the government and cut out health insurance companies. We really don't need a union. I have never trusted any union and personally think that every union is a blood sucker to their respective industries. Doctors pride themselves in their individual abilties. Some have a good bedside manner...others don't. Some are extremely intelligent...the rest are just intelligent.. Some are excellent surgeons and prefer to be in surgery and not deal with patients while others can spend hours talking to a single patient. We are individuals and should remain so. It's why patients cry when their doctor leaves. There has to be a way for us to go back to pay for service like dentists...like lawyers...like accountants...how do we do it ? We can opt out of medicare, medicaid, and all insurance. We can charge a fee and help patients to file for their reimbursement papers. But, how do we order test, CT scans, MRIs, admit patients to hospital, renew our Massachesetts medical licence without agreeing to accept all payors ? I think that all Americans should have health care coverage. We physicians can provide this. We don't need the government or health insurance companies in order to do this. We need all physicians, pharmaceutical companies, and hospitals in order to do this. Can we talk ?
We need to accept and adapt to the realities of the era in which we now live if we are to retain some independence.
It's so nice to hear from you again. You've had many excellent ideas in the past, and I hope you'll share your thoughts with the Sermo community. OBGYNFlyer and I tried to elicit interest in a nationwide IPA in multiple prior posts. Either physicians had no interest, or they had no understanding of the value of such an organization. I'd love to revisit the concept again.
And I would like to squelch the word "unionize". It is legally impossible. Period. We need to discard this word from our physician vernacular; it is legally pointless. Stop saying "unionize", "strike" or "collective bargaining." The sooner physicians can eliminate such nonsensical ideas, the sooner we can begin to make some progress.
In our most recent contract negotiations, we are demanding to either be (a) not indexed to Medicare, or (b) have a rate floor set, so that if/when Medicare is cut we will minimize our losses on the private contracts. We'll see how this goes.
Sermo Doc 3, your detailed comments are greatly appreciated.
Well, gosh...I knew that was true about ME, but I wondered about some of YOU... :-)
I asked my brother, the lawyer, why he had gone into law, as I heard it was just about the money. "Nonsense," he said, parking his Ferrari..."I seek justice for my clients."
I then checked with my father, the retired accountant, as to his interest in juggling numbers...was it just for the money? "Of course not," he said, offended. "I devoted my energies to helping people run their companies both effectively and legally, saving them millions, and much grief." And with that he got into his Bentley and drove off.
I pitied them their lack of insight into their own motivations as I sped down the road in my Mercedes...
I continue to believe that this is an ideal forum for the sharing of meaningful information that could result in the mobilization of physicians on a wide scale. Instead, what we have seen repeatedly is that threads rapidly dry up after real solutions are introduced (this one very shortly will), and there is no mechanism for the kind of follow up, information sharing and grassroots organizing that could result in meaningful coordinated actions by physicians.
Do you have any suggestions?
I'm sorry, I stand corrected. I meant physicians other than radiologists.
What I am referring to are the politicians, lawyers, accountants, etc who are trying to reform health care.
I think you will find more doctors focusing on malpractice.
You're absolutely correct. I've been preaching antitrust law for months, and few people understand it or are interested in tackling this legal behemoth. It's at the crux of our entire payment structure, and many attempts to get around it (large physician groups attempting collective bargaining) have been squashed by the FTC/DOJ. If you assume, as I do, that the McCarran-Ferguson Act won't be repealed, then your only logical recourse to return autonomy to physicians is to:
ELIMINATE THE THIRD PARTY PAYER SYSTEM.
This would mean no further direct participation with commercial insurers or Medicare. As physicians, we should be able to contract with the patient only. Let patients purchase their health insurance and deal with their insurance company. For those of you that worry about how they will navigate myriad prior authorization and insurance formulary issues, I'll remind you that the insurance system worked relatively well until the last 10 years or so. Since then, the sociopaths that run the insurance companies have forced physicians to shoulder the administrative burdens, which has left us with less time for patients and pushed practices to the brink of extinction, just so insurance executives and shareholder can make more profit. If the consumer interacts directly with their insurer, market forces would decrease much of this egregious behavior.
If you uncouple insurance and employment and stop participating with third party payers, I'm confident medical care would improve overall. Our life would almost certainly be better, and I'm sure I'd practice better medicine if I spent more time with patients and less time on administrative bullshit.
This is so crystal clear to me. Why not others?
1. Eliminate the anti-Trust Exemption for Big Insurance
2-10. Same as 1.
11. Will occur after 1-10.
this is the crux of all problems in healthcare today.
Thank you Sermo Doc 2.
Sandy -- you are very smart. My salute to you.
One qn to you all thinking brains:
Why dont we develop a system where every service and product is available free to anyone of any condition of monetary exchange or barter or prejudice or demand?
What is wrong with this scenario?
I just read 920 AM post and I all I can say is that it looks like our brains are clones.
Our ability to practice medicine the way it should be requires a conflict free interaction with pt. As long as we were not required to pay attention to money and were not wasting significant time on paperwork, it was possible to have conflict free interaction.
Now, these factors are threatening the very basic fabric of our system and I see young docs (including myself) deviating a lot from standards and ethics of quality medicine.
3rd party system breeds corruption, waste, fraud, abuse, misuse and overuse. It attracts greedy unethical people into our profession and that brings bad name and worse malpractice environment for all of us.
Many physicians personally may be able to live with it but system as a whole has no future but collapse.
Lamb vindaloo with naan bread. Burned lamb + overcooked rice = unhappy wife.
Simply agreeing that we would not accept payment from anyone other than patient would fix the problem 100% IMHO. However, it would be illegal unless laws could be changed.
It is clear that if Docs are paid by someone other than patient there is a conflict of interest. Or do you think HMO rules are always in patient's best interest?
No, of course not. Yet I think it much more likely that HMO rules are most closely alligned with the patient's interest than, say, Medicare rules...You can choose another HMO. You're basically stuck with Medicare.
You are 100% correct. In fact, the only sane physicians seem to be the psychiatrists who have been doing this for years.
Discussing non-participation with third party payers is NOT an antitrust violation. Discussing fees is.
This is pretty simple really. We must ALL say no to the third party payer system. The dynamics will change overnight, and your life will be infinitely more rewarding.
The Roaring Fork IPA never forbid contracting around the IPA itself. In fact nearly all physicians have contracts that were obtained outside of the IPA. How is that price fixing?
In the consent decree, the Roaring Fork IPA will simply have to messenger RBRVS contracts. FYI, RBRVS means Resource-Based Relative Value Scale (RBRVS). Resource-Based Relative Value Scale (RBRVS) is a schema used to determine how much money medical providers should be paid. It is currently used by Medicare in the United States and by nearly all Health maintenance organizations (HMOs).
RBRVS often decreases the monitary value of services based on a fixed pot of money that the Goverment has budgeted. As in 1989 a law was passed to rein in the escalating Medicare costs. This law in effect made mandated that Medicare spending be budget neutral. Therfore, RBRVS redistributes Medicare dollars and never increases Medicare dollars.
In that RBRVS often decreases payments for services, physicians are at financial risk if they sign.
The Roaring Fork IPA will messenger all contracts but historically poor contracts are rejected through a member by member vote. There has never been collective voting in this IPA.
In that insurance companies financially benefit in having a "Network" of contracted physicians, they will have to present to the IPA or individual physicians with Injenex based fee scheduled contracts.
Furthermore, Cost of Living Adjustments (COLA) will be eliminated from future contracts. All that means is that contracts will have to be renegotiated on a annual basis in stead of an automatic increase. More work for the IPA AND the insurance companies.
The Roaring Fork IPA has always been about educating physicians about an extremely complex payment system.
If I had my way, I think I'd like to build a home downtown in which the front of the downstairs was my office space, and the rest would house my family and myself. In this way, I could offer extended hours availability, and utilize my family to assist me rather than having to hire outside employees. I'd offer labs, Xrays, and EKG, and everything would have a price listed on a menu. I'd accept cash, checks and cards, and give a cash discount. I'd probably keep my LPN because she is good and can help speed me up considerably when we are busy. I would NOT buy the expensive EMR and would go back to handwritten paper charts - with three or four office visits listed on one page - listing only the info I need - not having to worry about documentation for audits or medicolegal protection. I'd post a sign stating that I don't have medical malpractice insurance, and would go bare (and of course proterct my assets).
Anyone who wants it can have an invoice and can file it with their own insurer if they want to, but we aren't going to file, and likewise, we aren't going to do prior authorizations for anything. If patients want that, they can do to their PPO assigned doctor, because I simply will not have the manpower to play that game any longer.
Doesn't that sound like nirvana? I wonder how many less patients I could see in a day and still make at least as much as I am taking home now.
I'm just daydreaming at this point, but it could actually happen.
I had a Vet once who lived and practiced as you described...lived very well.
But then, she was a Vet, not an M.D.
As a side note, Tom Campbell is now running in the Republican primary for Senate to face Barbara Boxer. Wonder if he'd be willing to back the same bill now?
Could it be the Insurance Lobby pays more than the BOmorons can resist?
Individual insurance rates soar in 4 states
From Associated Press
February 12, 2010 11:40 PM EST
TRENTON, N.J. (AP) — "Consumers in at least four states who buy their own health insurance are getting hit with premium increases of 15 percent or more — and people in other states could see the same thing.
Anthem Blue Cross, a subsidiary of WellPoint Inc., has been under fire for a week from regulators and politicians for notifying some of its 800,000 individual policyholders in California that it plans to raise rates by up to 39 percent March 1.
The Anthem Blue Cross plan in Maine is asking for increases of about 23 percent this year for some individual policyholders. Last year, they raised rates up to 32 percent."
my.earthlink.net
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When and how does this end?
My point is that I am interested in your IPA and I believe many office anesthesiologists in the northeast where we have our largest numbers, would be interested as well. I am talking about busy practices, wealthy, sophisticated demographics and misunderstood safe harbors.
Please contact me via Sermo.
www.opensecrets.org
Lord knows we NEED one.
And that 'we' is a BIG 'we'.
Never a million dollars a year better well spent....
After 1,584 responses to this post, it is interesting to speculate what motivates responder number # 1,585
any ideas?