No change with Blue Cross yet.
Sunday, January 27, 2008 Filed in:
Office
It turns out the reason the two docs
wanted to come out to my office had little to do with my
association with BCBS, but was more about they're wanting to see my
electronic medical records system (EMR). Physicians have found EMRs
to be something of an double-edged sword: while they promise
considerable time savings, data accessibility and reduction of
errors, they have (in practice) turned out to be (in general)
boondoggles. Most EMRs are outrageously expensive (requiring annual
fees in addition to the startup costs, if you don't pay the annual
fee or the company goes under your patient records could get locked
out and inaccessible), slow, cumbersome, and a waste of resources.
Often written by people with little clinical experience, they often
require the physician to conform to the system's way of evaluating
patients and may even work by having the physician select choices
from a menu for each phase of an exam. There is much promise in
using EMRs, but I haven't seen it realized in practice. I know 2
offices that tried to implement eClinicalWorks in their offices and
both abandoned it quickly despite having thrown thousands of
dollars at it.
I've been using an open-source EMR that doesn't cost an arm and a leg and I'm quite content with it. I had mentioned it to the doctor at my original BCBS PPO appeal and he asked if he could come out and take a look at it. I had forgotten about that, but that seemed to be the main reason they came out.
A week ago, I got another letter from Blue Cross saying they upheld their decision after the first appeal. So, if I want to keep having them cover the >50% of my patients with their insurance I have to either continue to fie appeals or give the same level of care they could get anywhere else.
I'm appealing again, but I expect it isn't going to last and the days of BCBS PPO coverage will come to an end. The tragedy is that this may lead to a domino effect with all insurances and going to a cash (or credit-card) only practice. It turns out that many physicians who practice a little off the conventional way are cash-only, so I'm not breaking new ground, and will probably survive. I'm mostly worried about all the patients who wouldn't be able to continue to see me: after years of inadequate care, they may get thrown right back to it.
I've been using an open-source EMR that doesn't cost an arm and a leg and I'm quite content with it. I had mentioned it to the doctor at my original BCBS PPO appeal and he asked if he could come out and take a look at it. I had forgotten about that, but that seemed to be the main reason they came out.
A week ago, I got another letter from Blue Cross saying they upheld their decision after the first appeal. So, if I want to keep having them cover the >50% of my patients with their insurance I have to either continue to fie appeals or give the same level of care they could get anywhere else.
I'm appealing again, but I expect it isn't going to last and the days of BCBS PPO coverage will come to an end. The tragedy is that this may lead to a domino effect with all insurances and going to a cash (or credit-card) only practice. It turns out that many physicians who practice a little off the conventional way are cash-only, so I'm not breaking new ground, and will probably survive. I'm mostly worried about all the patients who wouldn't be able to continue to see me: after years of inadequate care, they may get thrown right back to it.
BCBS, insurance, and the question of cost
Tuesday, January 08, 2008 Filed in:
Office
A couple weeks ago, I had a meeting
with one of the medical directors at Blue Cross. They're coming
tomorrow to meet with me here at the office.
A little over a year ago, BCBS PPO send me a registered letter warning me that I was "overutilizing." Apparently, since I spend more time with patients than most doctors, it was setting off alarms. When they noticed this, they sent me a letter pointing out that my utilization is higher than other family docs' and gave me 6 months to bring it down into the same amount as others.
During the ensuing 6 months, I tried to have shorter visits with patients, but I found that it is impossible to look at the entire picture of a patient in a shorter period. Some uncomplicated patients don't need much time and I get them out quickly, but a good proportion of my patients are complicated enough that we have to address 5+ issues in a visit and go over the different approaches to treatment.
So, in December I got a second letter saying that over the second period, my utilization had not gone down and had actually gone up. Therefore, they were going to disenroll me from the PPO. I could appeal their decision, and I did, which let to this meeting at BCBS office.
Now, let me mention that appealing this is not as simple a decision at it might sound. When I discussed this issue with some other physicians who have been practicing CAM for longer, they universally recommended against appealing and recommended just dropping insurance altogether. Some insurances have been known to report physicians like me to the state board of medicine, which can be quite rabid in some states about doctors who don't toe the conventional line in their practice of medicine, so there is substantial risk to getting involved in this. Even though everything I do is supported by research and improves my patients, just dealing with a board investigation can take a tremendous toll not only financially, but emotionally as well.
The meeting was interesting: their issue is that they have to keep costs down so that when employers are looking to buy insurance they will be competitive and be able to stay in business. It's clear from their practice that when they keep skimming off the top utilizers they put a negative pressure on all the rest who will scramble to reduce how much service they provide to they don't end up in the top and get themselves skimmed. In this endless quest to reduce costs, at some point quality will decrease and the patient will suffer.
My contention is two fold. First, having acquired a reputation for being able to fix things other can't, I attract sicker patients than a typical doctor would get, many of whom have already made the rounds of all the regular doctors and specialists, which requires a little more time and care than a typical visit. Second, by spending the time at the beginning to get people on the right path, total expenditures go down: fewer hospitalizations, ER visits and specialists.
Unfortunately, they don't tie total expenditures (including hospitalizations and specialists) to a provider. So, a doctor could come in looking good by kicking people out of his office after 6 minutes and charging a level 3 visit (getting in 10 visits an hour) for each one and then they end up going to urgent care or the hospital because they don't feel any better or they get a side effect they weren't warned about. In this scenario, while delivering lousy care, the doctor would be bringing in five times what I am by seeing people for 40-60 minutes and charging for a level 5 visit. Meanwhile, I'm spending time educating patients and looking at the big picture, keeping them out of the hospitals, and they accuse me of overutilizing as if I'm where all their money is going.
Using their own figures, this isn't born out: my "high" utilization comes out to less than $500 per patient per year. A single visit to the ER could cost more than that! A single hospitalization would cost several times what my care costs. Their money must be going somewhere other than to primary care docs and office visits. Since the monthly cost of a BCBS PPO plan at the U of M is $466 a month, they bring in over $5,500 for each patient each year. If my costs average out to $500 on those patients and I keep them out of the hospitals and other big ticket places, they're keeping over 90% of what they bring in. They could be doing pretty well if what I'm doing works out.
To the credit of the doctor I talked to, he seemed supportive of what I am doing with patients, but wasn't sure it is economically viable as an insurance reimbursable service.
So, tomorrow they're coming to see my office and tell me their decision. I hear there will be two docs coming to see me. I appreciate that this must seem to be important to them: taking a couple hours of 2 docs' time isn't small potatoes, so someone must think this is important. My hope is that they're coming with a real interest in maximizing care for patients and not just looking for an excuse to get me shut down. We'll see what happens tomorrow.
A little over a year ago, BCBS PPO send me a registered letter warning me that I was "overutilizing." Apparently, since I spend more time with patients than most doctors, it was setting off alarms. When they noticed this, they sent me a letter pointing out that my utilization is higher than other family docs' and gave me 6 months to bring it down into the same amount as others.
During the ensuing 6 months, I tried to have shorter visits with patients, but I found that it is impossible to look at the entire picture of a patient in a shorter period. Some uncomplicated patients don't need much time and I get them out quickly, but a good proportion of my patients are complicated enough that we have to address 5+ issues in a visit and go over the different approaches to treatment.
So, in December I got a second letter saying that over the second period, my utilization had not gone down and had actually gone up. Therefore, they were going to disenroll me from the PPO. I could appeal their decision, and I did, which let to this meeting at BCBS office.
Now, let me mention that appealing this is not as simple a decision at it might sound. When I discussed this issue with some other physicians who have been practicing CAM for longer, they universally recommended against appealing and recommended just dropping insurance altogether. Some insurances have been known to report physicians like me to the state board of medicine, which can be quite rabid in some states about doctors who don't toe the conventional line in their practice of medicine, so there is substantial risk to getting involved in this. Even though everything I do is supported by research and improves my patients, just dealing with a board investigation can take a tremendous toll not only financially, but emotionally as well.
The meeting was interesting: their issue is that they have to keep costs down so that when employers are looking to buy insurance they will be competitive and be able to stay in business. It's clear from their practice that when they keep skimming off the top utilizers they put a negative pressure on all the rest who will scramble to reduce how much service they provide to they don't end up in the top and get themselves skimmed. In this endless quest to reduce costs, at some point quality will decrease and the patient will suffer.
My contention is two fold. First, having acquired a reputation for being able to fix things other can't, I attract sicker patients than a typical doctor would get, many of whom have already made the rounds of all the regular doctors and specialists, which requires a little more time and care than a typical visit. Second, by spending the time at the beginning to get people on the right path, total expenditures go down: fewer hospitalizations, ER visits and specialists.
Unfortunately, they don't tie total expenditures (including hospitalizations and specialists) to a provider. So, a doctor could come in looking good by kicking people out of his office after 6 minutes and charging a level 3 visit (getting in 10 visits an hour) for each one and then they end up going to urgent care or the hospital because they don't feel any better or they get a side effect they weren't warned about. In this scenario, while delivering lousy care, the doctor would be bringing in five times what I am by seeing people for 40-60 minutes and charging for a level 5 visit. Meanwhile, I'm spending time educating patients and looking at the big picture, keeping them out of the hospitals, and they accuse me of overutilizing as if I'm where all their money is going.
Using their own figures, this isn't born out: my "high" utilization comes out to less than $500 per patient per year. A single visit to the ER could cost more than that! A single hospitalization would cost several times what my care costs. Their money must be going somewhere other than to primary care docs and office visits. Since the monthly cost of a BCBS PPO plan at the U of M is $466 a month, they bring in over $5,500 for each patient each year. If my costs average out to $500 on those patients and I keep them out of the hospitals and other big ticket places, they're keeping over 90% of what they bring in. They could be doing pretty well if what I'm doing works out.
To the credit of the doctor I talked to, he seemed supportive of what I am doing with patients, but wasn't sure it is economically viable as an insurance reimbursable service.
So, tomorrow they're coming to see my office and tell me their decision. I hear there will be two docs coming to see me. I appreciate that this must seem to be important to them: taking a couple hours of 2 docs' time isn't small potatoes, so someone must think this is important. My hope is that they're coming with a real interest in maximizing care for patients and not just looking for an excuse to get me shut down. We'll see what happens tomorrow.
Integrative Pediatrician new in town
Wednesday, January 02, 2008 Filed in:
Medical
I had the pleasure the other night of
having dinner with Richard Linsk MD, a pediatrician who has
recently opened an office here in Ann Arbor on south Main street.
He's focusing on the treatment of autism and ASD, and does general
pediatrics. He used to be in the University of Michigan health
system, but as he started doing more treatment of autism he invoked
the ire of the systems' autism "specialists" (who don't seem to do
much more then sedate the kids) and has had to branch out on his
own.
In talking with him that evening, I came to appreciate his tremendous honesty. Not only is he honest about his own limitations (an unusual feat in most doctors), but his honest perception of the shortcomings of conventional treatment are what drove him to expand into functional medicine and other modalities.
During dinner, I realized that he was one of the pediatricians I had rotated with in medical school (over 8 years ago). He was working out of a small building with a couple other pediatricians and I ended up spending most of my time there with him. Something about him made me think I had the most to learn from him, and in retrospect I think some of it was his willingness to seek the truth despite the pressure of being harried with a full (over) load of patients and those annoying medical students.
In addition to his regular office visits, he offers HBOT in roomy chambers (that you can rent out) and single-reagent immunizations. His website is www.integrativepediatrics.net.
In talking with him that evening, I came to appreciate his tremendous honesty. Not only is he honest about his own limitations (an unusual feat in most doctors), but his honest perception of the shortcomings of conventional treatment are what drove him to expand into functional medicine and other modalities.
During dinner, I realized that he was one of the pediatricians I had rotated with in medical school (over 8 years ago). He was working out of a small building with a couple other pediatricians and I ended up spending most of my time there with him. Something about him made me think I had the most to learn from him, and in retrospect I think some of it was his willingness to seek the truth despite the pressure of being harried with a full (over) load of patients and those annoying medical students.
In addition to his regular office visits, he offers HBOT in roomy chambers (that you can rent out) and single-reagent immunizations. His website is www.integrativepediatrics.net.
