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August 31, 2000

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Subject:  AMA discussion Reprise
Author:  pshaffer

I came upon this thread (the AMA is screwing you thread) after a few days of not being online, and there was a long thread already. I had reactions to much of it, and as I am in the middle of the situation, being a doc, I thought some would be interested in what I see. (to add to Philphool and raddr)

This will be long, but I think interesting to all. (I am not an AMA member, but I support some of the things they do (anti-tobacco) and oppose others.) Certain topics have come to the front and I thought it would be most clear if I addressed them individually.

Cost and medical care
Of course there is not a one to one correspondence of quality of care to cost, otherwise, Howard Hughes would still be alive. However, there are certain general trends. If I see a sofa for $50, I won't buy it, I'm pretty sure it won't last. If I see a cut rate doctor, I wonder "why is it he can't get the going rate" I have two illustrations.

1) A group of Amish north of here try to economize on their medical care by taking a caravan to Mexico every year to have all their ailments taken care of all at once for a cheap rate at some clinic. I saw a woman who had a major surgery for constipation down there. (she also had her uterus "adjusted", I don't know that's what they said) They had made mincemeat of her bile duct and she had several gallons of bile in her abdomen when I saw her. (This is a disaster, she may well die) There is no reason in the world for this surgery to have been done other than profit. It is costing a great deal to put her back together, as best we can.

2) A clinic in town was put together by internists and they got a lot of radiologic equipment to do their own imaging. At least some of it is total crap, and produces incorrect diagnoses. They also hired the cheapest radiologist they could find, who is not board certified. They are making money by hiring this person on the cheap. He is incompetent, about 1/3 of the time when I am asked to do a breast biopsy on one of their patients, I have to repeat everything they did, and then often there is no reason to do a biopsy. Cheap radiologist, cheap result. This radiologist is getting the most he can, and the quality is commensurately low. (By the way, the internists collect the same amount for the work off this cheap equipment that we do, they charge for the radiologists fee, and pay him 1/4 of what they collect, and keep the rest. Here is clearly an incentive for doctors to do poor work to make money, and I think it is unethical. Of course their patients don't know about this and if anyone criticized them publicly, in a forum that patients might hear about it, we'd get our butts sued, they have a lot of lawyers.

Natl practitioners database
Here's a juicy topic. I imagine that if someone had many more than the average, that means something. I am not in it, but barely escaped. I was sued because a patient says that I pinched him in a machine, causing him to jump violently, striking his shoulder and making it so he could not work. At the time of the alleged incident, he said nothing to us. We found a witness who saw him lifting an 80 kid over his head and tossing her around after the shoulder was supposedly injured. The suit was dropped after his attorney failed to file papers on time. If I had chosen my malpractice carrier less carefully, they might have refused to take it to court, found it cheaper to settle for $10,000, and my name would have gone to the malpractice database as a malpractitioner. In brief, this sucks. Fortunately, I pay more for a carrier who will fight things in court, some won't.

The comments already made that those who take on the cases that no one else will touch getting more than their fair share of the suits is accurate. Another important observation is that the incompetent doctor who has tremendous communication skills never gets sued. The competent doc who isn't so good with people gets sued frequently. Suits have more to do with how you handle angry patients than how good you are.

Insurance co's and gvt and reimbursement
Several have touched on this. I have several reactions.

The government: In an attempt to control prices they have done several interesting things. One was to give a single payment for a single diagnosis. This means that for a gallbladder operation, they pay a certain amount, regardless of how complicated the patient is. Thus, they put the doctor and hospital in the position of rationing care, the legislators don't have to take responsibility for it. Hospitals lose money on every Medicare patient as a result. They have to make it up on insurance patients, if they don't they go under, as three in Cleveland did this year, and several I am aware of are about to do. Ours is large and can sustain losses of 5-10 mil per year for a while. No hospital I know of is doing well right now.

The Govt also did an interesting thing in the 80's: they told us they were going to freeze fees but not until next year. I could never figure this one out, everyone knew they had to raise their fees as much as they could, because they might not be able to for another 10 years. Now what happens is there is an announcement at sometime during the year of what your payment will be in the next year and it has been decreasing steadily, with some modest upward adjustments here and there.

Insurance CO's: These people are snakes. We sign a contract with one of the large ones, beginning with A that you may have heard about recently. We find out 2 years into the contract that they are not paying us what they agreed to on many of the CPT's. (We are all small business people in this regard, we can spot check, but the CPT book is very thick, we don't have the people to check all these codes, and frankly we never expected out and out fraud). They never repaid, we considered a suit, but knew it would be futile, they have a lot of lawyers too.

How about this: a business man comes to us and says that he is going to act as the agent for insurance company Z who we have a contract with which is about up. A rather large contract. He says that we can't get the same reimbursement that we got last year, it will decrease substantially, but that is the best we can do. Oh, and for his service to us to act as a liaison between us and the insurance company, he takes 15% of what we get from the insurance co. At the next meeting, he introduces us to his friend who is part of the operation of the company also. His position is to act as a liaison between us and the aforementioned businessman. His fee? 10%. Really. So all these people try to force themselves between us and you the patient. The $1 you pay in insurance is seriously eroded by the time that it reaches us. Many of these people do absolutely nothing to improve care, they just get their money as sort of a protection racket. [...] I dated a nurse once who worked for this same insurance company as a person who called doctors offices to tell them that coverages were denied. She said she quit after a month because she thought it was unethical to do what the company told her to do, which was to find any reason to delay payment as long as possible.

FYI: In our business, we immediately write off 25% of our billings as uncollectable. These are the folks who simply can't pay, this is charity care. I don't know of another business that does this and I am proud of it, but we get no credit for it. I understand that our overall collection ratio is now under 50%, and I believe this is 50% of the 75% left after uncollectibles. IMPORTANT POINT: If you go to the web site for the fees, and think that is what the doctor gets, the foregoing hopefully will let you know otherwise. I think that if they are going to print fees, they should print also what the govt pays and what the average collection is. They should also print what the overhead the doc has to pay is. (I saw a story on CBS about a family doc in rural Maine whose practice took in about $180,000 last year. Not too bad you think, but his office expenses were 110,000. Malpractice came in somewhere, etc. In the end he made 27,000. He said the carpenters in town did better, and they weren't on call 24/7)

Choosing a doctor
message 16348. Some advice: I think that in order to choose a good specialist doctor, you need to consult someone who cares about you, who is knowledgeable in the area. Someone you can trust to do the best for you. It used to be that this was your doctor. I don't know if this still works in the era of HMO mandated 6 minute patient encounters. In terms of finding a good primary care doc, personally I would steer clear of anyone in an HMO. There can be some good ones, but they contractually have to place the health of the HMO above yours.

Policing their own
Intercst says in message 16363: I'm unaware of any profession (learned, or otherwise), from the clergy to doctors and lawyers to used car salesmen, that does a good job policing their own. The only real protection the consumer has is universal full disclosure. Anytime I have a union (and let's face it, the AMA and the Bar Association (lawyers) are no different than the Teacher's Union or the Teamsters -- their primary function is to protect their members) telling me I'm incapable of using information that effects me, I get real suspicious.

Some valid points. I guess I don't know what the final goal is here: 100% of the docs are in the top 1% of their class? Certainly, no profession is filled with perfect people. I think that we could do a better job. I have seen docs pulled off the job by others when they started to fail, but it probably doesn't happen often enough. Nevertheless, I do get a mailer from my state medical board every month that has about 50 docs a month I would estimate who have been disciplined. Many who have trouble don't get this far, and just lose their hospital privileges. I would like to see our profession be perfect, and to that end I think there is improvement that can be made, but our group has disciplined docs, and will do it again if necessary. We ARE different from the teamsters, etc. We got into this to help people, and when we see this threatened, we do take action.

Medical care in old age
Ogrecat said in 13368: I don't think I want to live like that. 50% of health care $$ is for the last 6 months of people's lives (please, someone, statistics). Every morning, my mother (78), and many older people, counts out all her pills for the day; she is also insulin dependent, so has all the blood testing and shots 3 times a day.

This is similar to what I have heard (30% in the last 3 months or so), in fact former Governor Lamm of Colorado brought this up in the early 80's as something to discuss, should we continue to do this. The AARP went after him hard. People do NOT want to talk about this. A friend who went to England made an interesting observation. All of the ICU beds there were filled with people 40 and less, most of ours are filled with people over 60. The difference is that when you are old in England and very sick you are cared for in a standard ward, much less expensive. I guess the inevitable conclusion is that you are "let go" of more quickly too. It used to be there that if you were over 60 and in renal failure, you just died. No dialysis, no transplant, just died. I don't think Americans will tolerate this.

Hmo fiasco
Seattlepioneer says in 16412: The article is critical of capitation plans, but I don't see a compelling reason why this has to be unfair.

Capitation plans inherently pit the financial well being of the system against the welfare of the patients. This is a built in conflict of interest of the most evil. It cannot be escaped unless you do not have a capitation plan. He implies that you balance the bad, or costly patients, with cheaper to care for patients and thus do OK. Not true, in each case a $1 saved and not spent on a patient is $1 in the pocket of the health care company. If you think business managers and the shareholders don't pressure the docs to cut costs whenever possible, well, you are just na�ve.

Physician dissatisfaction
All these things wear on your doctor. I don't know about you, but I want to go to a HAPPY doctor, I think paying him or her well is a GOOD idea. Many of the docs I know in their 40's and fifties are wanting to quit (myself included some days) This is new. Docs used to go to their 70's. I spoke with a family doc recently whose income has gone down every year for the past 4 and is down 20% this year. He can't stand the paperwork he has to do now for the insurance companies. In Mammography, many radiologists are simply dropping it because it is too litigious and it doesn't pay well enough to cover the hassle. (Raddr here is your opening�.)

And Finally
Someone recently said that he made an offer to someone of $4000 cash if he would agree to go back to the healthcare we had in 1960. No cat scans, if anything is suspicious in your belly, it is an operation instead of a cat scan. No mammography, your tumor just grows till it is palpable and incurable. No new chemotherapies, your chance of surviving other cancers is nil. No modern cardiology, you die of your first heart attack. There were no takers. It seems to me that access to the most modern and advanced health care is now regarded as an entitlement. (I think this may have happened in the 60's and 70's when all the big labor contracts instead of giving raises, gave health insurance, eyeglasses insurance, dental insurance. Hey, people got the idea they were being treated unfairly if they had to pay for ANYTHING.) People don't understand that we DO have to pay for this, and if we don't, it won't be there. Our people in the hospital who have responsible clerical jobs that we depend on to move info through the system are paid $2 less an hour than workers at Krispee Kream. They are leaving and we are having a serious problem. We are missing things because there is no one to move information.

(BTW, where is the grocery insurance? After all that is a real necessity and it is unfair if some people can't afford it. How about furniture insurance, I could go on�..)

We ARE living longer and it does cost some money. Would most people pay some substantial fee, say $10,000 on their 60th birthday if they could be guaranteed X more years of healthy life? This is what has happened in the last 50 years, but now that the people have the extra years of healthy life, they don't feel they want to pay for it, it seems.

Now to end on a positive note, an article about how much things have changed for the better in my specialty in the past 25 years.

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