The Sad Case of the Patient Protection and Affordable Care Act

[brookyone]

Re: The Sad Case of the Patient Protection and Affordable Care Act

A friend of mine is a family practice doctor. He was, at one time, practicing in a small clinic with some friends of his. A number of years ago he moved over to join the Mayo Clinic Health System. We were talking one night and he was lamenting the loss of the small practice he had with his friends. I asked him why he had made the move. He said when they started, their practice could get by with about 1.5 administrative staff people per doctor. He said it's easily 4.5-5.5 per doctor now, and was a prime reason why he felt he was "stuck" where he didn't really want to be. I found that sad.

Wouldn't that be a somewhat normal progression with a growing practice? Isn't that the objective of a private practice...more patients? I understand administrative / clerical has become far more cumbersome. Ridiculously so in many instances. That's pretty standard with any business. I have pretty extensive experience in claims administration in a few other industries outside of medical. A commonality is whomever is ultimately paying claims establishes policy & procedure for those providing services which involve claims for reimbursement. It isn't just the health services industry that are required to navigate an intense, constantly changing maze of requirements or procedures set by the entity paying the claims. Just like health insurance companies...the goal is to withhold that payment as long as possible and deny reimbursement per failure to cross any T or dot any I. For the record...I think it's been established we can point the finger at health insurance companies as a culprit per this thread topic and probably acknowledge that was the case well before healthcare legislation. Or so I've gathered from les...whose experiences and frustration remind me a great deal of a former similar administrative position I had.

 

[Rover]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Fascinating and intelligent discussion especially for this place! I'd ask a question regarding the "govt makes everything more expensive" comment. Could part of that be because they're paying for people who otherwise would simply not get care and therefore be more likely to pass away or suffer more untreated ailments? Medicare has been around for my entire lifetime, so I have no perspective on medicine pre-1965. But it seems to me that yes, while I'm sure overall medical costs are higher via govt mandates it also has to be true that a lot of people driving up the costs would be #$%^ out of luck otherwise. Society today has evolved to where you can no longer barter for healthcare with your local doctor for a couple of chickens or an offer to fix a transmission so I'm not sure less govt intrusion, as in less Medicare/Medicaid would do anything the improve the system although as always I'll defer to the experts on this one.

 

[FlagDUDE08]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Wouldn't that be a somewhat normal progression with a growing practice? Isn't that the objective of a private practice...more patients? I understand administrative / clerical has become far more cumbersome. Ridiculously so in many instances. That's pretty standard with any business. I have pretty extensive experience in claims administration in a few other industries outside of medical. A commonality is whomever is ultimately paying claims establishes policy & procedure for those providing services which involve claims for reimbursement. It isn't just the health services industry that are required to navigate an intense, constantly changing maze of requirements or procedures set by the entity paying the claims. Just like health insurance companies...the goal is to withhold that payment as long as possible and deny reimbursement per failure to cross any T or dot any I. For the record...I think it's been established we can point the finger at health insurance companies as a culprit per this thread topic and probably acknowledge that was the case well before healthcare legislation. Or so I've gathered from les...whose experiences and frustration remind me a great deal of a former similar administrative position I had.

The point that is trying to be made is that, given the same number of patients, more administration is needed in today's world. Therefore the cost of business to cover just the administrative costs, given you have to pay these administrators, has trebled to quadrupled. Granted the bottom line hasn't necessarily risen by this factor because the physician's labour rate hasn't changed (although any associated products cost may change), but you probably get the point.

However, I would not put all of this on insurance companies, because that's been an effective wash since the 40's. The biggest culprit is the government regulation, because at least one of those administrators is required to ensure compliance. Tack onto that a monopoly created by the government called Medicare. I call it a monopoly because, in order to receive Social Security retirement funds, you must be enrolled in Medicare. I won't go through the rest of the details again as it'll practically turn into talking points; just look earlier in the thread.

 

[FreshFish]

Re: The Sad Case of the Patient Protection and Affordable Care Act

I'd ask a question regarding the "govt makes everything more expensive" comment. Could part of that be because they're paying for people who otherwise would simply not get care and therefore be more likely to pass away or suffer more untreated ailments?

That's a relatively small part of the equation, at least based on my experience, though of course I'll defer to those with more current direct everyday contact with the system.

> You have mandated coverages whether the insured even wants them or not (e.g., I think NY State requires every individual plan to cover chiropractic; at one time you could get a plan that would not cover "routine" maternity although it would cover both the newborn and also any complications of pregnancy).
> at one time you'd have separate coverage for "major medical" and "hospitalization" so that you could get each one from a different insurer if you wanted; now everything is all rolled up into one whether you want it that way or not
> Much of the care that once had been provided through charitable entities is now being paid for by government instead (not quite the same as what you said and also related to it)
> You have mandatory benefit minimums and deductible maximums (it used to be cheaper to get one plan with a benefit cap and then another really high deductible plan with no benefit cap; you can't do that any more).
> Indirectly, you sometimes have state laws that tilt the outcome of tort cases one way or another.

And of course, you have the aftermath of WWII wage-price controls that still leave tremendous pricing distortion in their wake. Just imagine how different it would be if, starting in 1946, everyone bought coverage in the individual market and no one received coverage as part of their employment benefit package!


Finally, there is a very important distinction between saying "(excess) government involvement increases the expense" compared to saying "all the increase is due to the government." I'd say, roughly, that there are four main components:
> unintended consequences due to well-intentioned yet poorly-thought-out government "meddling" (okay pick a different term if you want, you get my drift, see above)
> improvements in quality (you'd expect to pay more for a better product, no?)
> improved longevity. Like the brain teaser about the British army introducing new gear for the soldiers, and head injuries increased by 2,000%, and they were absolutely delighted! Things that once killed people now can be cured, which means those people then subsequently receive additional care they never would have received otherwise (the most extreme example of course would be reductions in infant mortality rates). this factor then feeds into the two above so you get synergistic effects.
> people don't see their total bill. if I ran an insurance company, I'd make sure people saw the entire bill for everything, including what the insurance company paid for (weird that our dental insurance works that way but not our health insurance). People think they are getting something for next to nothing and so overuse the system's resources compared to how they would behave if they themselves had primary responsiblity to pay for it.

 

[FlagDUDE08]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Fascinating and intelligent discussion especially for this place! I'd ask a question regarding the "govt makes everything more expensive" comment. Could part of that be because they're paying for people who otherwise would simply not get care and therefore be more likely to pass away or suffer more untreated ailments? Medicare has been around for my entire lifetime, so I have no perspective on medicine pre-1965. But it seems to me that yes, while I'm sure overall medical costs are higher via govt mandates it also has to be true that a lot of people driving up the costs would be #$%^ out of luck otherwise. Society today has evolved to where you can no longer barter for healthcare with your local doctor for a couple of chickens or an offer to fix a transmission so I'm not sure less govt intrusion, as in less Medicare/Medicaid would do anything the improve the system although as always I'll defer to the experts on this one.

I can understand your concepts, but once again, execution falls flat. OK, so there's a government reimbursement plan. Decent concept. Could costs be higher? Sure; just look at my last post for a few reasons. The only problem is the government only has so much money to cover those reimbursements. I don't think I need to tell you what happens when you run the press. Could you keep taxing the rich? You could, but what happens when they either run out of money or expatriate? You decide to set specific rates for reimbursement, or price ceilings. Practitioners decide not to participate. Then, you put in legislation to force them to participate. They decide to retire because it isn't worth the cost. If you need an explanation as to what happens then, look at ANY urban gas station in the mid-to-late 70's. Instead of strengthening health care, you're actually destroying the supply.

 

[DrDemento]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Brooky-There is a lot more to it. I used to spend 65 hours per week seeing patients. I hated to go home. Jenny ran my office and we detested Sundays because we had to wait until monday to get back to work. By the time we closed the office (and the major reason we did close) i was seeing patients for about 20 hours per week and spending 40 hours per week either on the phone with Medicare/Insurance carriers or dealing with the mail from Medicare/Insurance carriers. As you might guess, I am a very compulsive physician. I still love doing what i do and certainly wish it could be the way it was.

Les: I wish we had a simple solution but since the government has been so involved in determining what is the best way to provide medical care for the population for the last 50+ years, there is no quick fix. They have had enough time to screw things up royally. They use all sorts of worthless statistics to pass rules and regulations that simply make the system more cumbersome, more chances for fraud and abuse (by providers and patients alike), and unwieldy. If anyone out there right now thinks that they are getting the best and most attentive medical care please raise your hand. In the government's attempt to contain medical costs they have just introduced more and more types of providers (whether scientifically proven and valid or not) into the equation to take a slice of the medical money pie. In another post I asked the query-is medical care a right? Is food a right? Is housing a right? With the follow up-then is everyone entitled to the same medical care, food and housing? If not-are we entitled to a minimum standard of food, housing and medical care? And who defines what that minimum is? These are basic questions that need to be addressed before we can make any valid attempt to manage the cost of medical care. Obviously i do not know the answers. I simply know from numerous personal anecdotal examples i could give-that I have been restricted from giving the best medical care and the best advice and medications by people who have never set foot in a medical school or even treated a patient. We seem to be on the same page-but with a slightly different perspective. I am no longer as active in the practice but i still do consultaion work-totally gratis. I have not charged for medical care or advice in 11 years. I sometimes wish i could just sit back and relax and do nothing-but i love what i do far too much and the feeling of providing help for someone was the absolute number 1 reason I went into the field.

 

[DrDemento]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Fascinating and intelligent discussion especially for this place! I'd ask a question regarding the "govt makes everything more expensive" comment. Could part of that be because they're paying for people who otherwise would simply not get care and therefore be more likely to pass away or suffer more untreated ailments? Medicare has been around for my entire lifetime, so I have no perspective on medicine pre-1965. But it seems to me that yes, while I'm sure overall medical costs are higher via govt mandates it also has to be true that a lot of people driving up the costs would be #$%^ out of luck otherwise. Society today has evolved to where you can no longer barter for healthcare with your local doctor for a couple of chickens or an offer to fix a transmission so I'm not sure less govt intrusion, as in less Medicare/Medicaid would do anything the improve the system although as always I'll defer to the experts on this one.

Rover-The population expansion has of course a lot to do with everything. Limit the population growth and the cost of medical care would certainly fall. But there has also been an explosion in the number of providers (not all of them physicians but even if you simply counted MDs the numbers are far greater). The government's thought process went something like this--increase the number of doctors and that introduces competition which causes prices to fall. WRONG. Every doctor, and now every provider of any sort, wants to make a living-and they all see as many patients as possible and do as many tests as they can which of course INCREASES the cost of care. As i mentioned-i have no quick fix. In fact I am not sure I have even a slow fix. Unless someone wants to bite the bullet and simply say 320 million people is enough to take care of.

 

[DrDemento]

Re: The Sad Case of the Patient Protection and Affordable Care Act

The point that is trying to be made is that, given the same number of patients, more administration is needed in today's world. Therefore the cost of business to cover just the administrative costs, given you have to pay these administrators, has trebled to quadrupled. Granted the bottom line hasn't necessarily risen by this factor because the physician's labour rate hasn't changed (although any associated products cost may change), but you probably get the point.

However, I would not put all of this on insurance companies, because that's been an effective wash since the 40's. The biggest culprit is the government regulation, because at least one of those administrators is required to ensure compliance. Tack onto that a monopoly created by the government called Medicare. I call it a monopoly because, in order to receive Social Security retirement funds, you must be enrolled in Medicare. I won't go through the rest of the details again as it'll practically turn into talking points; just look earlier in the thread.

Interesting point-i would love for someone to post a relaible source for a number which shows what percentage of money is spent on medical care going to the doctor providing the care versus the percentage that is spent on medical care that goes for the administration of care. I think a number of people would be surprised to see those figures.

 

[FreshFish]

Re: The Sad Case of the Patient Protection and Affordable Care Act

In another post I asked the query-is medical care a right? Is food a right? Is housing a right?

While I don't have the answers, I do notice that, in the Declaration of Independence and in the US Constitution, all but one of the rights are to intangible things: freedom of speech, of religion, of assembly, the right to vote, protection against cruel and unusual punishment, to be tried by a jury of one's peers, etc.

There is only one right to a tangible, physical good in the US Constitution, and that is the right to own a gun.


Personally, I think this is a reflection of the wisdom of our Founders. How can you possibly guarantee people the right to food if there is a drought? Right to housing if there is a tornado or hurricane? with any physical good there is potential scarcity. Society needs to figure out how to allocate resources on its own without the government stepping in and picking one method over another, at least in the US that I love. If you want guaranteed security, move to a country that promises it; but be prepared for a lower standard of living as a direct result of that promise.

The poorest people in the US today are better off than all but the richest people in many other parts of the world. We lose perspective sometimes. Who wants to be a millionaire in Syria or Iran these days?

 

[FlagDUDE08]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Rover-The population expansion has of course a lot to do with everything. Limit the population growth and the cost of medical care would certainly fall. But there has also been an explosion in the number of providers (not all of them physicians but even if you simply counted MDs the numbers are far greater). The government's thought process went something like this--increase the number of doctors and that introduces competition which causes prices to fall. WRONG. Every doctor, and now every provider of any sort, wants to make a living-and they all see as many patients as possible and do as many tests as they can which of course INCREASES the cost of care. As i mentioned-i have no quick fix. In fact I am not sure I have even a slow fix. Unless someone wants to bite the bullet and simply say 320 million people is enough to take care of.

Perhaps this is why we see/hear those "Questions are the Answer" PSAs when it comes to health care? I know you've heard it a few times during the intermissions of RPI hockey games; you couldn't have been THAT plastered.

 

[FlagDUDE08]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Interesting point-i would love for someone to post a relaible source for a number which shows what percentage of money is spent on medical care going to the doctor providing the care versus the percentage that is spent on medical care that goes for the administration of care. I think a number of people would be surprised to see those figures.

You said that, around 2000 or so, it was 1:2, yes? I'm not saying your office is a model for the entire country, of course...

 

[LynahFan]

Re: A system that doesn't want to change

Re: A system that doesn't want to change

Yes, this is a very concrete example that illustrates just how myopic and foolish it is to say that increases in health care costs above the rate of inflation is somehow a "problem." We are getting more in increased value in return for what we pay; ask anyone who today gets arthroscopic surgery compared to the scar that was left behind 25 years ago from knee surgery and they'll tell you that quality and value are better today relative to the cost than it was then!!

Yes, the new surgery is certainly better than the old, no question. The "problem" isn't that a new type of better, more expensive surgery is available - the problem is that surgeons realize they can make more money with the new than the old, so many/most of them stop offering the old, so then the only option becomes the new and a lot of people can't afford it. Thankfully (sarcastic), the government then steps in and mandates that insurers must cover the new surgery so that people can get knee surgery, so then there is even less incentive for doctors to offer the cheaper option, and voila, every single knee surgery costs 10x what it used to.

It would be like the government mandating that loan companies must cover loans for 200+ mph supercars (regardless of ability to pay). How many family sedans would be left on the market if the car companies knew they could make the most money by being in the supercar market?

 

[DrDemento]

Re: A system that doesn't want to change

Re: A system that doesn't want to change

Yes, the new surgery is certainly better than the old, no question. The "problem" isn't that a new type of better, more expensive surgery is available - the problem is that surgeons realize they can make more money with the new than the old, so many/most of them stop offering the old, so then the only option becomes the new and a lot of people can't afford it. Thankfully (sarcastic), the government then steps in and mandates that insurers must cover the new surgery so that people can get knee surgery, so then there is even less incentive for doctors to offer the cheaper option, and voila, every single knee surgery costs 10x what it used to.

It would be like the government mandating that loan companies must cover loans for 200+ mph supercars (regardless of ability to pay). How many family sedans would be left on the market if the car companies knew they could make the most money by being in the supercar market?

Very perceptive and a very fair analogy.

 

[DrDemento]

Re: The Sad Case of the Patient Protection and Affordable Care Act

You said that, around 2000 or so, it was 1:2, yes? I'm not saying your office is a model for the entire country, of course...

Dude-i don't have that figure available. I can certainly tell you the percentage of hours spent by my office on the two. I would just love to see how much out of evry health care dollar the government and the insurance industry spends by giving it to the doctor and how much is spent in some other fashion. I think the result would be very informative.

 

[FlagDUDE08]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Dude-i don't have that figure available. I can certainly tell you the percentage of hours spent by my office on the two. I would just love to see how much out of evry health care dollar the government and the insurance industry spends by giving it to the doctor and how much is spent in some other fashion. I think the result would be very informative.

I believe all you would have to do is read a bill that has been passed that contains the government budget. I'm sure FOIA would allow you specifics.

 

[FreshFish]

Re: The Sad Case of the Patient Protection and Affordable Care Act

I believe all you would have to do is read a bill that has been passed that contains the government budget. I'm sure FOIA would allow you specifics.

Are you an actuary?

it seems like every time I ask an actuary - any actuary - a question, they always tell me how to calculate the answer on my own.

 

[joecct]

Re: The Sad Case of the Patient Protection and Affordable Care Act

I believe all you would have to do is read a bill that has been passed that contains the government budget. I'm sure FOIA would allow you specifics.

No government budget has been passed in the last few years. The Appropriation Bills can be found here: http://thomas.loc.gov/home/approp/app13.html

 

[DrDemento]

Re: The Sad Case of the Patient Protection and Affordable Care Act

I believe all you would have to do is read a bill that has been passed that contains the government budget. I'm sure FOIA would allow you specifics.

Years ago I received some piece of paper from the AMA with some numbers on it but I trust them as far as i can throw them. I also remember something from my American Board but it was far too long ago to be relevant. It is not an easy number to come by-I have searched all over the web. I can find all sorts of gross numbers that show what the total expense may be in any given year-but it is never broken down as to % paid to physicians, % paid to administration, etc. So much of what is spent is just not carefully accounted for.

 

[FlagDUDE08]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Are you an actuary?

it seems like every time I ask an actuary - any actuary - a question, they always tell me how to calculate the answer on my own.

Do you typically pay the actuary first?

To answer your question, though, I am not an actuary.

 

[leswp1]

Re: The Sad Case of the Patient Protection and Affordable Care Act

A friend of mine is a family practice doctor. He was, at one time, practicing in a small clinic with some friends of his. A number of years ago he moved over to join the Mayo Clinic Health System. We were talking one night and he was lamenting the loss of the small practice he had with his friends. I asked him why he had made the move. He said when they started, their practice could get by with about 1.5 administrative staff people per doctor. He said it's easily 4.5-5.5 per doctor now, and was a prime reason why he felt he was "stuck" where he didn't really want to be. I found that sad.

-When I started we had a receptionist/biller, LPN, Dr and me (in my first practice) 25 yrs ago. This was more than enought to cover everything. So it was 2 providers (sorry Doc) and 2 ancillary staff. (We also farmed out transcription but that was optional)
-By the time I left we had 8 providers (3 full time, the rest PT) /8 nurses, 4 billers, 4 receptionists, 2 file clerks, office manager, (and a partiridge in a pear treeeeeee)
-When I came to this practice 10 yrs ago it was the Doc- FT, me PT, a nurse and a receptionsit/biller
-About yr 2 we added one more NP full time and another nurse to make it 3 providers/2 nurses.
-Over the next few yrs we needed to add specialized billing people as the insurance issues were so complex one person could no longer handle it.
-Billing issues eventually became so complex we had to outsource the billing. The billers could not keep up with the billing and keep current with the all the changes. We were losing 10s of thousands of dollars because they could not keep up with the volume of resubmissions.
-We added another nurse and receptionist (both PT) as the volume of patients, calls and need to triage increased.
-Office manager was added next because there were so many administrative issues to deal with credentialing, multiple insurance requests for data/chart review we needed a dedicated person to do it even with out sourced billing.
-we added a telephone tree (HATE THIS!!) because the number of calls exploded from patients needing things and the receptionists could not keep up.
-We now have 3 nurses- all FT, 3 receptionists- all PT, outsourced billing. The Doc now has to take 2 afternoons to do admin work to deal with all the AQC, requirements, various meetings with hosp regarding all the initiatives the PHO gets us into that affect our reimbursement, etc. All ancilary staff work on the numerous requests for data from the insurance co. at least one afternoon a week.
-when I started the amount of admin work was negligible. The Dr is doing about 50/50. I am about 1/3 admin, 2/3 pt care with documentation taking as much time as the actual patient care.

As primary we are the 'gateway (unpaid of course) that is supposed to get our patients to comply with seeing us rather than self referring to where ever else they decide to go. We already are required to call every patient that goes to the ED/minute clinic/ doc in the box to follow up on their visit and determine whether there was true need. If there wasn't we are supposed to chastise them. We have to send documentation for every one of these visits regarding our determination to the PHO.

As of this AM (I thought of this thread immediately) we had a meeting and there is serious thought to adding someone who does nothing but track the initiatives for the various insurance companies/medicare. The PHO now has signed on to a Medicare initiative to track all Medicare patient billables for redundancy/ overuse of specialists, etc. to cut the costs. (I understand the motivation to decrease redundancy but I don't have time for this BS). This will not change our renumeration but we are supposed to document a discussion with every Medicare patient every year regarding the PHO participation (and ours by default) and give them the option of declining to participate in this initiative. The PHO of course sent out the packets to all Medicare pts but have no standardized processes regarding what we are supposed to do other than who is the gateway and responsible for the education of the patients (um, yup- us).... guess who gets no renumeration but much chastisement if people are not changing their behaviors..... guess who is supposed to find the time to do this..... The I saw 3 people that needed to have this 'discussion' today- wasted about 30 minutes of my time to explain stuff that we do without being required to do it but now, because we need to prove to the PHO we did it I have to formally document the BS- where no one knows- not in the chart, there is no form. Maybe on my left cheek??!!

Les: I wish we had a simple solution but since the government has been so involved in determining what is the best way to provide medical care for the population for the last 50+ years, there is no quick fix. They have had enough time to screw things up royally. They use all sorts of worthless statistics to pass rules and regulations that simply make the system more cumbersome, more chances for fraud and abuse (by providers and patients alike), and unwieldy. If anyone out there right now thinks that they are getting the best and most attentive medical care please raise your hand. In the government's attempt to contain medical costs they have just introduced more and more types of providers (whether scientifically proven and valid or not) into the equation to take a slice of the medical money pie. In another post I asked the query-is medical care a right? Is food a right? Is housing a right? With the follow up-then is everyone entitled to the same medical care, food and housing? If not-are we entitled to a minimum standard of food, housing and medical care? And who defines what that minimum is? These are basic questions that need to be addressed before we can make any valid attempt to manage the cost of medical care. Obviously i do not know the answers. I simply know from numerous personal anecdotal examples i could give-that I have been restricted from giving the best medical care and the best advice and medications by people who have never set foot in a medical school or even treated a patient. We seem to be on the same page-but with a slightly different perspective. I am no longer as active in the practice but i still do consultaion work-totally gratis. I have not charged for medical care or advice in 11 years. I sometimes wish i could just sit back and relax and do nothing-but i love what i do far too much and the feeling of providing help for someone was the absolute number 1 reason I went into the field.

Thank you. I so envy you. As I listened in the meeting today to the Doc trying to sell why all the BS would be worth it I just wanted to go to work at McDonalds. I found it so sad that she buys into all the BS of being compliant with all the stat gathering as a help to patients. How is it ehelpful that I spend less time with my patient than I do making sure all the stuff is documented/billed with crazy codes to 'capture' what I did? It is so bad I would almost pay to work gratis.