I was just getting ready to announce
that I had achieved the Triple Crown of physician recognition
in Hour Detroit’s Top Docs issue,
appearing on TV, and the Vitals.com
Patients’ Choice Award) when a got a Google alert that I
the runner-up in the Current Reader’s Choice Awards for
“Place to get alternate
healthcare”. (Yes, half of these spelled my name
wrong: Malcolm Sickel and Malcolm Sickles, but it’s not a big
So let’s recap:
1. Hour Detroit, an oversized glossy of all things fabulous around Detroit, starts the ball rolling by featuring me as the first holistic physician ever in their magazine.
2. Fox News Detroit, the big local TV station, has me come in for a spot on their morning news.
3. Vitals.com, the main website that scores doctors, gives me the Patients’ Choice award for doctors who have “received near-perfect scores as voted by patients.”
4. Current, Ann Arbor’s monthly newspaper of events and all things hip, has an annual reader survey and in the category for “best place to get alternate healthcare” (which I didn’t know existed), I get the runner-up position after Castle Remedies, a great retail store for homeopathics and supplements. The fact that I landed first place after a retail shop that gets a lot more traffic than I do is quite flattering.
Of course, I must give credit to the Crazy Wisdom Journal for featuring me first back in 2006. A nice way to get the ball rolling.
So, thank you to everyone who has put their faith in me and voted for me. I’m honored. A friend of my brother’s said that I should write a book, but I’m already pretty busy. Maybe if I had a better idea of what people wanted to read...
- People looking for appointments can get frustrated by the wait. Fortunately, we have Gaia who can see patients sooner. We also keep a wait list for people who want to get in earlier than the appointment they schedule.
- When an appointment is months away, people often forget when the appointment is or that they ever made the appointment. So, we end up with new patient appointments with no patient. This is a problem for us (it’s hard to pay the bills when we’re not seeing patients) and it’s unfair to the other people trying to get in to see us.
A bunch of college students and a few doctors and other health professionals all got together and brought all the medications and supplies we could. We lived in a hacienda in bunk rooms and rode a bus 1-2 hours to the sites where the locals lined up to get help. Despite the long bumpy and dusty rides, heat, and other hardships (of which the flight back was probably the worst when a delayed flight made us lose all our connectors), we all kept good spirits and played soccer with the local kids (who were kind enough not to embarrass us).
We're going to have to reschedule everyone from that week and I won't be around for the week. Sorry about the short notice, the plans just came together.
Gaia brings a strong background in mind-body medicine to the office and has trained with the Center for Mind-Body Medicine. He has been involved in natural approaches to healing for many years in the Ann Arbor area and has worked with the University of Michigan's Complementary and Alternative Research Center.
He has been eagerly picking up Dr. Sickels' approach to medicine over the past few weeks and will often start the work-up on patients and sit in on visits, in addition seeing patients on his own.
Learn more about Gaia here.
What does that mean for my patients with BCBSMi PPO? I will no longer be in the lowest tier of reimbursement: rather than just the regular co-pay (which varies from plan to plan), visits would be subject to the next tier up payment, which also varies from plan to plan. In general, it is often a 20-50% copay and subject to the deductible (which, of course, varies from plan to plan). So, it's time to dig out that benefits book you got when you enrolled and see what your plan will do for visits to doctors who participate in BCBS but not in the PPO.
Also, if you want to find a provider in the network, it easy enough: go to the BCBSMi website and look up your plan and see who's covered.
Other interesting things from the meeting:
The fundamental issue is that I don't fit in their business model, which groups things together by objective criteria (like doctor's specialties) and then looks for places where costs are going out of the normal range for that group. Since I'm not practicing the way the average family doc is practicing (which also happens to be the reason many people seek me out), I'm and outlier and not compatible with their plan. In a way, it acts as a gatekeeper for people in their PPO: to go to Dr. Sickels, patients would have to need to see me enough to justify their going out of the PPO network.
They did bring up the previous entries on this blog about the audit, seemed a bit miffed about them, and asked me why I posted them. As I told them, the potential for them take all that money back is a big deal for me: it can put me out of business and leave my patients out in the cold. As far as I know, I didn't sign away my right of free speech when I signed up for the PPO. I think it's important for people to know what's going on and if my office suddenly closes, I want people to know why.
I don't know what this means for MiChild. I suspect this means it will no longer cover visits and they'll have to pay to see me themselves. Too bad they can't take the thousands of dollars I've already saved them and use it for other people.
Assuming they'll decide that some amount of the charges aren't justified, they'll give me an opportunity to appeal, but it'll still go to some "physician reviewer" (who may get bonuses for rejecting claims, as documented by Linda Peeno MD in SiCKO) who will just re-reject them. I asked one of the people who came to collect all the records what happens if they demand all the money back and the answer is that I just get nothing: I can't bill the patients, I just spent that time for nothing.
Let's be clear: no matter how much time I actually spend with a patient and document clearly in my records and precisely, they can decide that it wasn't justified and demand the money back, regardless of how much benefit the patient got. In that circumstance, I would be better off working at McDonald's to pay my bills.
At this point, they've only asked for a few patients' records for 8/06 to 7/07. If they decide that they don't want to pay me for those visits... I'm having enough trouble paying the bills now. What's to stop them from deciding, "hey we concocted reasons to deny a bunch of claims and got a bunch of money back, let's get more!" Can they eventually go back over the the whole past year and retroactively deny those claims, too? This would mean that any payment I get from BCBS PPO would need to be held in trust for 18 months in case they decide to pull their money back.
This is a risk of taking any insurance. Medicare can be even more risky: if insurance decides I did something against their inscrutable rule-books, all they can do is demand their money back. If medicare decides something I did somehow violates their volumes of arcane tomes, I can go to jail.
So why would I be so dumb as to set myself up for these risks?
Is it that it's the only way I can get patients and get paid? No, I'm booked up for 4 months to get in to see me as a new patient. If some patients don't come because I'm not in their network, I'll still be fine.
It's because my patients will lose out. The patients who can't afford to pay out of pocket or who can't afford the higher co-pays for out-of-network will get thrown back to the 6 minutes for a prescription and get-out-of-my-office treatment that is becoming the standard of care these days.
Why did I even bother to appeal the last decision to kick me out of their PPO? For these patients who wouldn't otherwise be able to see me.
Let me tell you about one of my early patients, a young lady who have been developing upper respiratory infections so often that she was going to the ER monthly. She had gotten to the point where she was allergic to just about every antibiotic, so there was nothing the doctors could do to help her.
Her mom brought her in to see what other options she had. We tried some IV vitamin C and it worked fantastically. I was a bit nervous about using it in someone so young, so I started with small doses, and she got a little better but it would come back. I progressed to larger doses and got the infections to clear up. It worked so well, in fact, that her grandmother told me that the only side effect of the IV vitamin C treatments was that her eczema would clear up.
Once we got the infections under control, we did some searching for the reason for her problems and found that she had several food allergies. Taking her off those foods kept her from getting sick and now she gets sick less often that the average kid. She hasn't been back to the ER since her first appointment with me, over two years ago, saving the insurance considerable money.
She is one of the patients who will lose out. She's can only see me via the SCHIP program in Michigan called MiChild that allows working people who can't afford insurance to get their kids into BCBS PPO.
However, it has become clear that if I continue to subject myself to insurers' whims, I will be forced out of business and won't be able to help anyone. My days of participating in insurance are coming to an end.
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.
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.
So, now the front desk is in the other room and (9 months on... hmm...) nearing completion of the remodeling.
If you're wondering what screening thermography can do, it is a great way to do non-invasive breast cancer screening (more info here) (preferably in addition to mammography, but also for people who don't tolerate mammography or for whom mammography otherwise isn't a good idea), find the source of pain and look for other irregularities. You can learn more here (yes, it's in New Zealand, but it's a great compendium of quality information) until I get my own information pages set up.
"The only ones who can claim to be above suspicion are those who are so much sought after that their cured patients are immediately replaced by fresh ones." -George Bernard Shaw, in the preface to The Doctor's Dilemma
Mr. Shaw was no fan of physicians. Would he have come to see me? Tough to say, but if the wait for a new patient appointment is anything to go by I should have satisfied his concern. The wait for new patients can be a few months, but give me a call regardless.
Four new rooms in the back, a lab, a lounge for patients getting IVs, more windows and ventilation, eco- and allergy-friendly flooring, breathing room for everyone.
We'll see what we can do with the four rooms once we see how much it all costs. At a minimum, the IV Prep will return to the back in a real room with a sink and counter, storage will go to the back, and eventually my office will move back one room and the front desk will move into the front room, leaving more room for a family to sit in the front. The hyperbaric chamber may end up with its own room, too.
Some of the color choices are tricky when the place isn't built yet, but I hope they'll work out.
In order to pack up this room, Dr. Alspector (who used to occupy it) has moved across the parking lot (to 190 Little Lake drive #5), and has graciously let us house our hyperbaric chamber over there until we have space for it once again. It is still usable, so call for an appointment.
During visits at our office, you may hear sounds of the construction in the back, but don't worry, they're not about to drill through the wall during your visit (though it may sound like it).
-update- I found the article online, but who knows how long it will remain. Get it here: http://crazywisdomjournal.squarespace.com/s/holisticdocs.pdf
So, you should be able to get a live person most of the time when you call, and if not a call back within a day. They've called back most of the old messages (except for things I specifically need to deal with), so if you haven't gotten a call back it must have gotten lost in the transition so give us another call.
I've also set up some more talks for the Summer, so check the events page for the updated listings.
Finally, with my being in the office 5 days a week now, I have appointments available in a much closer time frame, so no more month-long waits for new patients (at this point).
The goal of all this is to improve the care I'm giving patients:
An easier website makes it more likely to be up to date.
A more open office is nicer and makes room for a reception station. The reception station means I'll be hiring some help to take some of the work off my shoulders (I can't answer the phone while I'm seeing patients, but if I'm booked solid the whole day, I get no time to check messages or schedule new patients, leading to absurdly long waits for people to get calls back).
Less time in Flint means more time at my office, so I'll finally have some openings to schedule the new patients who have been leaving me messages (I've been getting them, but haven't had openings to put new patients in).
Things are still hectic, but should be settling down soon (at least in geological time).
So, the take home message is that is you've tried to contact me and haven't gotten a response, I'm working on it and haven't forgotten you. Do realize, however, that I'm currently booking for a month from now.