Settling for treatment

I was talking to some of my neighbors today about IPT (Insulin Potentiated Therapy), and how it uses lower doses of chemotherapy with fewer side effects than conventional chemotherapy and may even produce better outcomes (though there’s not much research on it). One of them asked why more doctors aren’t learning how to do this. To me, the reason seems straightforward in our current medical system: there’s no economic incentive to do it.
In order to learn to do IPT, a doctor needs to take time off work to learn to do it. That means no income for that time (actually, losing money since overhead costs remains when the doctor isn’t working) without much potential for increased revenue after learning the treatment. Hospitals and offices make money from delivering chemotherapy by marking up the drugs they are giving in addition to charging for services. More chemo and higher priced chemo (recent cancer drugs cost 20-200 times more than older drugs and may not give any more substantial benefit) means more money to keep the offices open and funds to cover fancy new cancer clinics and free art therapy classes. So, using less drug (IPT typically uses 10% of the usual dose) or older drugs (a vial of an old medication can be as little as $15 where a vial of a newer drug like Topotecan costs nearly $2000 per vial and others cost more... remember that chemo may use multiple vials and costs to administer the drugs will add substantially to the price) would substantially reduce the revenues of these offices and hospitals.
With big organizations, money drives everything they do and a potential loss of income (switching from larger margin chemos to smaller amount of cheaper drugs) isn’t going to contribute to a healthy bottom line.
It is an unfortunate reality that in this country there’s more interest in doing more expensive procedures than a less expensive procedure that may perform better.

Good-bye BCBS PPO

Well, that was quick. I went out to the Southfield offices of BCBSMi PPO on Wednesday (after the big snowstorm, so it took me nearly 2 hours to get there, but they were gracious enough to still see me despite my being late, though I did leave my lights on and had to push-start my car when I got back out). Friday morning, we got the letter that said they were upholding their decision to remove me from the PPO, effective march 21.
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.

The joy of chart audits: and justice for...

Today I got to experience a "chart audit" by Blue Cross. This is where BCBS sends me a registered letter informing me that they want to look at some of my patients' (and their insurance holders') medical records. They go through the records to see if my documentation of the visit justifies the charges they got. The trick is that they send the records to their physician reviewers and if the charges aren't justified in their view then they reject it and want me to give them the money back.
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.

No change with Blue Cross yet.

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.

BCBS, insurance, and the question of cost

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.

Insurance companies reject bioidentical hormones!

I just got a note from about the latest way that insurance companies are working to help the drug companies: by refusing to pay for compounded hormones. You'd think they'd be smart enough to see that by covering compounded bioidentical hormones they could be saving themselves drastic amounts of money: Premarin or Prometrium are about $45 a month each and testosterone gel or patches are upwards of $200 a month, while compounded estrogen (usually a combination of estrone, estradiol, and estriol), progesterone, or testosterone each start at around $25 or so a month (they can go a little higher at higher doses). Add the additional costs of higher incidences of breast cancer in women taking Provera and they could really be making out by supporting bioidenticals.
Aetna's going to stop on October 1, while BCBS changed their policy back in May (note that BCBS cites an unscientific 2001 FDA study that even the FDA doesn't support).
As the note I got says: If you are an Aetna or BlueCross BlueShield customer, please contact your employer’s HR department and ask them to petition your health insurance company to reinstate coverage of bioidentical hormones and other compounded medicines. Remind them that healthy employees are productive employees and your health depends on these drugs. Your doctor has decided that compounded medicines such as bioidenticals are the best treatment option for you. Both your employer and your insurer have a responsibility to provide you with the medicines you need at a reasonable cost.

BCBS limiting prescriptions?

I got the Blue Cross "Physician Update" the other day and noticed something alarming. In their quest to reduce expenditures, they are trying to limit what they are spending on prescriptions. Some of the things they are doing are reasonable (using generics where reasonable), but one is disturbing: "Enforcement to Exclude Off-Label Coverage", which "Helps curb prescription drug misuse."
"Off-label use" means using a drug for something other than what the FDA approved it. Keflex (cephalexin) is an antibiotic that has an approved use (the manufacturer did studies to show a benefit for) bacterial infections. There is a common off-label use for preventing bacterial cardiac infections in people who could get them from dental procedures (it is used for this in people who are allergic to penicillin, the usual medication for this).
In addition to the incredibly common off-label prescribing all physicians do, alternative doctors are prone to use things for off-label uses that aren't so common: Omacor (fish oil) for reducing joint pain, Clomid (clomiphene) for increasing low testosterone in men, low-dose naltrexone (LDN) as an immune stimulant in all kinds of diseases (MS, pancreatic cancer, rheumatoid arthritis...), etc. Indeed, it is the innovative use of current medications that drives progress and benefits patients without increasing costs.
Now BCBS seems to be saying that they will know better then the doctor what is appropriate for the patient. Maybe they are the ones practicing medicine without a license?
If you combine this with their threatening to take me off their PPO for "over-utilizing" (spending more than the average 6-15 min appt with patients and getting thorough testing on people), they're not my favorite insurance company right now.

Hyperbaric Oxygen and the "noncovered conditions"

Hyperbaric Oxygen Therapy (HBOT) is quite useful for a number of conditions, though the medicare laws have a curious and unusual statement about HBOT: a non-covered conditions list. Most therapies' entries in the medicare laws don't even list covered conditions, so why does this specifically name 22 conditions as being "non-covered"? This is especially interesting because the 22 conditions are all clearly effectively treated by HBOT.
The last issue of Hyperbaric Medicine Today has an interesting article about how this happened. You can go read it yourself at The article starts on page 7, you'll have to scroll down to it in the acrobat file yourself. Interesting reading.
If you'd like to read some information about HBOT by physicians who use it, try
here. You can read a (relatively) short bibliography of research on HBOT here.

Here is the medicaid list of noncovered conditions:
1. Cutaneous, decubitus, and stasis ulcers
2. Chronic peripheral vascular insufficiency
3. Anaerobic septicemia and infection other than clostridial
4. Skin burns (thermal)
5. Senility
6. Myocardial infarction
7. Cardiogenic shock
8. Sickle cell anemia
9. Acute thermal and chemical pulmonary damage, i.e., smoke inhalation with pulmonary insufficiency
10. Acute or chronic cerebral vascular insufficiency
11. Hepatic necrosis
12. Aerobic septicemia
13. Nonvascular causes of chronic brain syndrome (Pick's disease, Alzheimer's disease, Korsakoff's disease)
14. Tetanus
15. Systemic aerobic infection
16. Organ transplantation.
17. Organ storage.
18. Pulmonary emphysema
19. Exceptional blood loss anemia
20. Multiple Sclerosis
21. Arthritic Diseases
22. Acute cerebral edema

As the author of the "noncovered conditions" list points out, there is no law against using HBOT for these conditions, they are merely off-label uses for HBOT. There are also articles about using HBOT for
migraine and Lyme disease (which medicare presumably won't cover either, nor, by extension, would insurance companies). And since I have a special interest in MS, I dug up this page which is the beginning of a discussion on HBOT for MS.

Why do I take this interest in HBOT? I managed to get my hands on a modest chamber and have been looking into using it therapeutically.