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Saturday, October 31, 2009

New article on Knol - HMO: Details and overview

Check out my new article on Knol about HMO's and how they work. You can check out the article here.

Tuesday, October 27, 2009

Over-utilizing care, a real problem in health care

I'll answer the question right off the bat - I am not 100% sure as nobody can be. This problem is way bigger than any one person alone could ever fix. That being said there are many issues I encounter on a daily basis in my line of work that are a big problem with health care in this country, when you look at the bigger picture.

Working for a surgeon you are forced to learn the particulars of every physician you answer to. You must figure out what Dr. A wants order for pre-op testing on a patient, what tests they must have had prior to ever coming in to meet with the doctor, which patients they want at the beginning of the day vs. the end, how many patients they want on a Friday, which surgeries you can put where and the list continues all the way down to what coffee they want when they come into the office. This tedious assistance can lead you to discover things you may or may not wanted to have known about a doctor.




In the current health care system there is a huge burden of proof that hangs over doctors heads.

Example:
Patient presents to surgeon with abdominal pain and a CAT scan that shows gall stones. Surgeon explains all the benefits, risks, and alternatives with the patient - always making sure to explain that there is without a doubt pain after surgery. (after all you just got cut open! Pain and a little tiny bit of blood are not that worrisome symptoms in and of themselves)

The procedure was text book and goes without complication, the patient feels fine and goes home. Two days later he is complaining of very slight itching at the incision site.

Now - there are basically two choices; order a test to rule out complication or trust his/her many years of medical knowledge that suggest that slight itching at any wound site is normal as the wound begins to heal. BUT - in the twisted spider web of medicine today - the doctor orders another CAT scan to rule out pulmonary effusion or other post-op complications.

Why? Because if the doctor doesn't and the patient dies many months later of something completely unrelated; he/she could still be held liable to an extent if the doctor could not prove they had taken every single possible precaution after surgery.

/end example

Now that alone sounds a bit harsh - what harm is one CAT scan doing the health care system?

The answer is - very very very little. But look at the bigger picture of the ideology behind it and the mentality it has brought upon doctors today. There are several doctors which I have worked with that have developed a nasty habit of ordering vast arrays of what are quite frankly, unnecessary tests and treatments at the slightest hint of anything.

- patient coughed 2-3 times after he woke up after surgery = doctor orders CAT scan to rule out pulmonary embolism (this is quite common after surgery due to the tube they insert down your throat in anesthesiology)

- patient who had a mastectomy complains of limited range of motion in the shoulder 2 days after surgery = doctor orders physical therapy, massage therapy, neurology consult and home health nursing (any surgeon knows that there is no such thing as pain-free surgery especially mastectomy - it can take many months for the range of motion to return to normal in some people but this particular doctor has actually ordered all that 2 days after surgery)

These are only 2 of the numerous extreme examples of over-utilization of care. Let me be clear however that I am in no way saying that patients don't some times need more care due to circumstances specific to their treatment - of course, everyone is different. Playing it safe by ordering tests is how some doctors do things - it becomes a problem when you see the ones who are ordering large amounts of intensive and costly care for people who truthfully don't need it, and in some cases don't even want it. I hear on a daily basis from some patients "well I don't see why the doctor wants done but I guess he's the doctor"

I also would like to point out this is not my opinion alone, there are several physicians who have said something about the exact situations which I wrote about and agree that they were ordering unnecessary care - simply because it was available.

Even now are you still saying "well what harm is it?" Think about who's paying for it and not just with money either.

The insurance may or may not pay for the care (as is with almost any situation to be quite honest) but no matter what - they monitor and track all the stuff they pay for or are asked to for the simple purpose of tracking trends in care. Insurance companies require review of services that they have determined are being over-utilized by physicians for this exact reason. Insurance companies also charge higher premiums and cut cost of care for people who really need it for this exact reason as well - they have to pay for the staff to review the millions of cases because of the fact that the services are over-utilized in the first place. 



Physicians should not be ordering what they know to be unnecessary care or testing on a patient just because it is available at the time - this drives up the cost of care for everyone in the long run. On top of the bigger picture, more long term consequences - the testing itself may or may not be harmful to the patient (ie. unnecessary radiation, or exposure to radiological agents or dyes) but even if it is unharmful the patients insurance is still being billed and thus the patient still pays for part of that care through copays or coinsurance payments and ultimately through rising premiums.

Tuesday, October 20, 2009

Young cocky doctors and why they are bad for the entire country

I am touching on this subject for a brief moment before I really rip into it hard and take my time to write a decent article on it; so here's your preview.

Doctors; we all need them - lets face it. But none of us ever like going to them. I work in a doctors office and yet I never understand why we bother asking patients "how are you today?" when they come in for a visit, if they were anything other than bad/shitty/sick/terrible/dying - then why the f**k would they be there?

The problem with doctors is ego. For decades doctors have been a sort of 'big shot' character - with expensive cars, tons of money and overall just being the one who calls the shots. Well that has had a huge effect on the ego of the type of people who decide to become doctors. My office has several surgeons fresh out of their residencies, and I have never met anyone in my entire life had; such a loud mouth, so little tact, so little common sense, so little compassion for people, and such a hotshot mentality.

You might think having a doctor who has self confidence is good. Well you're 100% correct - but you are also blind to the fact that these young energetic 'go-getter' type surgeons and physicians - are victims of what I would call the 'small man' syndrome; merely compensating for their own insecurities; and I have seen each of them on multiple occasions get themselves into cases that were way WAY over their heads simply because they wanted to be the cowboy.

Why would I say such a seemingly mean thing? Because truth be told - as surgeons; if I we're dying on the ground and they were the only doctors around, I would just say no thanks!


More on this to come!!!!!

Thursday, October 15, 2009

Healthcare - Things you should know (Part II)


II.                   Hospitals

a.      Communication is key
A hospital can be one of the most confusing places you may ever be in your life; or it could be high above what you expected and really impress you. The former is far more common for those of us who are not very well off financially. One of the fundamentals lacking in many hospitals today is communication. Without communication it all falls apart in the world of healthcare.
Though I work in a private medical office, we closely interact with hospital staff almost constantly; scheduling tests, scheduling procedures, calling for reports, taking messages to relay to the doctors, taking consult requests and so on. Working with hospitals has taught me one very important thing – hospitals are the masters of misdirection.
When it comes to what patients are told in any aspect of their care, whether it be; the status of their care, the coverage their insurance is going to provide, their next plan of treatment, or their communications with the doctors – what they are told is almost always a bureaucratically vague and ambiguous representation of what’s really going on. This is generally due to not just bad communication but a complete lack thereof – one doctor or nurse isn’t passing on the vital information to the next properly; and there you have the first break in the chain. All it takes is one piece of vital info to slip through the cracks and the patient is put at risk – many times this happens continuously throughout their stays due to the sheer chaos going on in most low level hospitals today.
All this miscommunication and bouncing around of patients from one doctor/nurse to the next leads to the eventual confusion of any patient and when it comes down to ‘who do I blame for this mess?’ the hospitals always play the same card – they find a way to blame it on us every time.
The hospitals I am collectively referring to are notorious for:
-          Doing the wrong test on the patient; then claiming that the office scheduled it incorrectly
-          Cancelling patients because they needed the spot for something emergent; then telling the patient that we called to cancel their appointment
-          Deciding at the very last second that the test we ordered needed to be changed to a slightly different one; then making patients wait (I’ve heard of up to 5 hours) while we change the authorization – telling the patient we authorized the wrong thing
-          Cancelling major, life saving surgeries  because they decided the night before that they wouldn’t make enough money off of it; then they refuse to tell patients and leave it up to our office
-          Giving patients medication being oblivious to their allergies; then telling the patient that the doctor’s office did not inform them of the allergies
-          Nurses many times refuse to tell patients anything claiming that the doctor didn’t tell them anything yet; even though they were already given the answer hours prior

All in all it comes down to accountability they refuse to explain anything that someone else can explain to them, passing the buck down the line indefinitely until patient’s finally give up asking questions. As mind-numbingly irritating as all that is to the doctor, and their office – think about the big picture, the real reason it matters; and that is the effect on patient care – devastating.

b.      Remember – hospitals = big money
If you thought that your care matters one bit to a hospital at almost any point, you are delusional. Hospitals are about making the most money out of the least amount of care provided. This is quite simple if you examine the medical billing system.
Billing of any procedure is done with codes; diagnosis code (ICD-9) and procedure code (CPT/HCPCS). Diagnosis codes are really just references to supporting the medical ‘necessity’ of any given procedure code. For example you had a breast mass (ICD code 611.72) so you had an excisional breast biopsy (CPT 19120). Fairly simple right? Trick question!!!! WRONG!!!
You see when you are talking about the treatment of diseases, illness, conditions etc. nothing is really chiseled in stone. Every patient is unique, as is every case any doctor will ever see. As such the terminology used in Current Procedural Terminology (CPT) books is written to leave large room for interpretation.  
Example – Patient is involved in a minor motor vehicle accident, ends up with a severe abrasion to oh lets say both forearms (basically – wicked hamburger meat road rash). The doctor cleans out the wounds, removes some excess tissue, and uses a skin graft to begin the closure of the wound. The diagnosis is abrasions to both forearms; your treatment was debridement and removal of devitalized tissue and secondary closure with a skin graft.
This particular example should be billed with 2 procedure codes. There are 4-5 separate codes for the debridement (cleaning) of the wounds alone; varying by how extensive the procedure was, how far down the wound penetrated, and the area of the wound treated. There are more than 20 different codes that can be used for a skin graft – because there are hundreds of variations. Basically as you would expect, the bigger the wound, the deeper the wound, the more difficult a wound is to treat and close – the more money the doctor makes.
You would think the doctor would be bound by some sort of regulation to bill for what he did and in a sense you are correct; however the doctor can just as well dictate excessively in the report and therefore it looks to the insurance payer like a legitimate claim.
Hospitals will almost as a rule of thumb over-bill and under treat basically every patient they see. There is a huge grey area in the billing aspect of care. When I say huge I mean that more than 90% of the CPT codes used are open for a vast amount of interpretation – much like the law.  Also consider that this example was merely the easiest to explain without writing a novel; but the underlying theme applies to the majority of care received at any hospital.
Tragically many patients never understand how negatively all of that impacts their overall well being.
So…How does it actually affect patient care?
-          Contrast materials used in radiological tests (such as CT scans, CT angiography, MRI) are almost always comprised of substances that impair kidney function (thus the reasons for the blood levels commonly tested prior to any such studies – BUN & creatinine; these are indicators of kidney function) for anyone with diabetes; too many scans with contrast can cause kidney failure if incorrectly monitored, and for those who are allergic to the contrast materials it can be lethal.
-          Any radiological exam when done by the book is still using exposure to radiation to gather the images. Need I explain in any more detail what can happen when you get too many
-          Wrong test? Need a do-over? Guess who’s paying for both?
-          If a procedure in interventional radiology goes incorrectly and a vascular surgeon isn’t on hand – patients can end up needing amputation of limbs
-          Just going through such a bad experience at the hospital in general can make a patient waste precious time finding all new doctors and an all new hospital – hoping all the while their illness doesn’t kill them

c.       The telephone effect
If you ever played telephone when you were a child – you know as well as I that at the end of the game the message is usually nothing even remotely related to what it started out as. It seems odd but you can apply the same theory to healthcare. On average your information must be coordinated between at least 5 to 6 medical personnel for treatment of any given problem (depending of course on number of employees of course)
Who’s in the need to know:
1.      Got the flu
-          Primary doctor
-          Primary doctor’s staff
-          Insurance company
-          Phlebotomist
-          Laboratory staff
-          Pharmacist
-          Pharmacy staff

2.      Need a CT scan
-          Primary doctor
-          Primary doctor’s staff
-          Referral coordinator
-          Insurance company
-          Phlebotomist
-          Laboratory staff
-          Pharmacist (if contrast is used)
-          Radiologist
-          Radiology staff

3.      Need a surgery
-          Primary doctor
-          Primary doctor’s staff
-          Referral coordinator
-          Insurance company
-          Cardiologist (if you have any kind of cardiac condition)
-          Anesthesiologist
-          Surgeon
-          Surgeon’s staff
-          Surgeon’s referral coordinator
-          Phlebotomist
-          Laboratory staff
-          Radiologist (for chest x-ray – standard pre-op exam)
-          Operating room scheduling
-          Operating room nurse (scrub nurse)
-          Director of surgery
-     Coding department
-     Billing department

I don’t feel I need to explain the inherent margin of error that comes with all this. There’s even a saying we use in our office all the time when a patient’s care is literally being over-complicated to the point that it puts them at risk – Too many cooks in the kitchen. Onto the end of that I’d add – and too many pots on the stove, and too much food in the pots, and too much food to cook!
Oh what a tangled web we weave.
This article was a bit different from the last in its focus, but when you take it all in and really look at the big picture it all comes back on the patients and at the end of the day – they are paying the price for healthcare industries major shortcomings.
Let me add a short disclaimer here – This absolutely does not apply to all hospitals, in fact the ones that don’t absolutely scare me are actually extremely well run facilities; usually tertiary care facilities. That being said, the well run facilities (out of those that I personally work with) make up less than 10% of the total. The really scary part is that they are all certified by multiple agencies and healthcare review panels designed to ensure the safety of us all when under the care of hospitals.

Monday, October 12, 2009

Healthcare - Things you should know (Part 1)

Healthcare – Things you need to know

This article will not include names of doctors, patients, specific insurance companies and or IPA’s. It is written with the sole intent of informing the reader about some of the things going on in the world of healthcare today and is not intended in ANY way, shape or form to be slanderous of any specific company, group, facility, insurance payer, provider or organization.

I work for a small group of specialists and I handle all of the insurance forms, procedures and the like. However I also do back office patient care as well. By all means this does not make me the leading authority on healthcare and health insurance; but it’s shown me enough to open my eyes to the inner workings of the healthcare system enough to really make an impact.

I. Insurance

a. All Insurance is wonderful insurance – until you try to use it.

That saying has stuck with me; playing in the back of my mind every single time I hear a patient try to tell me – ‘my insurance is great they’ve always paid for everything’ the next thing that goes through my mind is that’s because you haven’t ever needed a specialists services. As long as you are doing as all insurance wants you to do, which is visit a family physician (aka. PCP, primary physician, General practioner) for checkups so they can say you’re doing well and getting your routine mammogram, prostate check or what have you, they are keeping a huge majority of what you are paying them and paying the provider their carved down, penalty deducted tiny percentage of what the service was actually worth. It’s when you are found to have a serious problem; something like breast cancer, pancreatic cancer and so on that you have now become a huge risk to them and then they begin their hunt. They will look for anything in your past history or bills that isn’t right, and when I say anything I mean anything; maybe you got a prescription for an expensive drug and failed to mention it to a nurse or doctor one time (for any reason whatsoever) – that would be something they would love to find. Subsequently they may have grounds to cancel your coverage just for that.

b. Call three times – get three different answers (PPO Specific)

Many IPO’s utilization departments are on a constantly shifting routine of what answers they will give, what they are trying to deny that day, and even what name they will use. Say for instance I call and need to pre-certify and fairly routine outpatient procedure – someone named Dave C. answers the phone, takes all the information and determines that the services are not a covered benefit of your policy. If I know from my experience this procedure is standard of care for the given diagnosis; you know what I learned after awhile? Call again, you’ll get someone else – and you may or may not get a different answer. Now if this is the case I call a 3rd time just to verify that it is the correct answer, if the third time I call the answer changes again; guess what I am forced to keep trying – moving higher up the ‘supervisor’ chain until I find someone who will give me a semi-honest answer (hard as I try this effects patient care, and makes the office look bad through no fault of its own).

Now take for example you actually had a policy that actually excluded such routinely covered services (and yes it is not uncommon to run into certain insurance plans to do) I have to call you and tell you that it is not covered, and you either need to pay cash or sign a decline of treatment. I would generally inform you that it might be wise to contact them yourself (as if you hadn’t already thought of that right) like clockwork – every patient that fits into this example will call me back and tell me (usually in a very angry tone of voice-understandably) that they were told by Fred X. that no one by that name works there and the services are covered they just need review by the Utilization department. This goes on sometimes around 2 or 3 times before a concrete written decision is made. The punch line – not one insurance company out there will ever authorize, pre-certify or pre-determine services without a disclaimer just before you hang up that says ‘this is not a guarantee of payment…’ But when you put the word ‘authorized’ in big bold writing – that is obviously the assumption of the patient.

c. Health Maintenance Organizations (HMO)

It saddens me to start off by saying, that up to 40% of the patients who come into our office every single day are completely unaware that they had an HMO and they even handed us the card; they thought they had Medicare/ Medical (medi/medi) but low and behold they signed the contract with the provisions and yet they are somehow oblivious.

I won’t say they are evil because that would be slander, and I won’t tell you not to join them – because that may also be construed as such. What I will say is this; I would highly recommend that you read that contract YOURSELF as many times as you need to, to understand what it means before your mind is made.

Part I. How it works

An HMO is much different than a PPO type insurance (also EPO, POS, etc.) in that; you may not self refer to anyone, responsibility for your general well being is almost always belongs to your PCP, all services are contracted to a specific doctor or facility and you receive services from that facility/provider only. Second opinions are considered on a case by case basis (this can take months), and rarely they will ok you to go out of network if for a very special reason your care could not be facilitated with an in network provider - they don’t tell you the real reason for their scrutiny because they don’t want you to know a few things.

- You go to your PCP (primary care physician) first - always

- Based on clinical info or tests he/she orders makes a diagnosis

- If it requires surgery or other measures he refers you to the specialist that your HMO is contracted with

- Specialist consults you and gives his opinion to the PCP

- Your PCP submits the recommended treatment to your HMO for authorization

- (if they approve it) You are treated and sent back to your PCP

On the outside, it all seems a tad more complex than just setting an appointment with whichever doctor you chose but not overbearingly so.

The structure of an HMO can be extremely complex but when you get through all the IPA’s and insurance carriers and you find out which HMO you are talking about (and I have never heard a patient who was actually able to tell me which HMO they were contracted with) they are fundamentally the same.

At the top you have the medical director, the final decision maker; they are making the big bucks and every piece of care he can reasonably deny without violating his contracts is money in the bank to him or her. The medical director is generally a licensed medical doctor, some still practice medicine in a clinical setting – but we will get to that later. Directly underneath the medical director you have the Utilization Review (or utilization management) department which is comprised of some nurses (administrative nurses not the kind that work in the E.R. etc.) and other licensed medical professionals who are there to do the simple reviews that are clearly defined by the medical policies. The reviewing nurses usually have say over the lower level review staff, if one of the people who answers the phone in this department and can’t answer your question they are generally putting you on hold to ask their nurses who will in turn review the guidelines of your HMO and make a decision.

Health Maintenance Organizations (HMO’s) contract with specific physicians, or facilities for certain services – if they can they will capitate the services which means that the provider under capitation does NOT get paid for each patient; a provider who is under a capitation consults and treats up to XXX hundred patients a month (through the given HMO) for whatever capitated services they are contracted to provide for a monthly check set at $XX,XXX. Meaning that whether he/she see’s you one time or 5 times and does a major surgery he/she still only gets his/her set pay. Only after he/she saw more than however many hundreds of patients his/her capitation permits would they get paid any extra money.

Part II. How it affects patients' care

What if I was to tell you that – if you are enrolled in an HMO there is a chance that the medical director of your HMO could potentially be an employee of your PCP or vice versa? As in your PCP - Doctor A could work for Doctor B who owns their group practice and Doctor B also could happen to own the HMO they are both contracted under? That sounds really confusing but if you can understand it – it is a huge problem.

Example:

Patient: Tom

Patients Primary Care Physician (PCP): Dr. Two

Patients HMO: XPLAN

XPLAN ‘s Medical Director: Dr. One

Dr. One has owned his practice comprising of himself, Dr. Two and several other doctors who specialize in Internal Medicine for XXX years. Dr. Two and the other physicians are legally employed by Dr. One. Tom has a pancreatic mass discovered by Dr. Two on an MRI. Dr. Two asks Dr. One what to do; Dr. One wants it removed by a surgeon – he refers to the contracted surgeon. The surgeon says it is not something that can be performed at the community hospitals he goes to – that you would need treatment at a university hospital (or other special setting facility). He sends his recommendation back to Dr. Two who submits to XPLAN for authorization – XPLAN is not contracted with any specialized facilities of the sort; therefore it is considered an out of network expenditure which must be reviewed by the medical director Dr. One. Dr. One decides he is safe denying the service as not contracted and out of network because the plan has not contract with the other facility and therefore it would be an ‘unjustifiable’ expenditure.


Some other problems that HMO’s have:


- PCP’s are held more accountable for following up on things like breast masses. This makes them more subject to penalties if they were to miss anything therefore if you have an ultra-sound or mammogram report that even says something as vague as ‘incomplete study; further workup needed’ many PCP’s will automatically send you to a surgeon ASAP without telling you anything specific. Some of them even make it standard policy to send directly to a surgeon anytime you have screening exams for breast masses – regardless of the results. For the majority of patients who were referred haphazardly and without justification, this turns out to be a waste of the patient’s time and they can’t help but be honestly frightened to tears when their regular doctor sent them ASAP to a surgeon without giving them any details: and to top that off they really can’t handle it if they have a surgeon tell them the results were normal. Their argument is valid – why was I referred if results were normal? From a professional standpoint this is a catch 22 for a surgeon because he/she will hurt their business reputation if the honest answer is given – that their primary doctor didn’t want to be responsible for it.

- Patients who are not familiar with the way things with work in an HMO are often very angry when they find out they have to wait for authorizations, can’t be seen without a referral and all the other hassles that come along with the HMO they signed up for. These people offered me a plan, told me it offered 100% coverage, they didn’t say anything about referrals and doctors being in network or capitated services, I’ve never heard of such nonsense in my life! Why do you think they omitted those minor details? They also probably left out your co-pay and the reduced coverage if you use out-of-network providers too.

- By the time a patient gets to a specialists office, they don’t expect to have to consult the doctor. The patient has waited 2 weeks for the appointment, what do you mean you’re not taking out his gall bladder in the office? He has to wait another 2 weeks for the surgery to be authorized and scheduled? Yes I am afraid that is how it works; you can’t bill a surgery without a matching consult/history and physical – unless you go through the E.R. which would cost you way more money. But even if you do that, the hospitalist on call for your HMO would probably just send you home and try to have it handled outpatient to save the HMO money so he/she didn’t get your E.R. visit carved out of his capitated rate.

-

You thought your healthcare was based on what you needed to be healthy? It should be, but sadly sometimes it isn’t. In case you are wondering, yes I have seen a situation closely resembling this happen. I am forced to omit specific details due to confidentiality and the fact that I could lose my job if I were to release names and so on.

I will be expanding upon my argument in the next post on healthcare; hospitals! But my hands are tired for now. I hope any readers can take this information for what it is worth. Again these are my observances, experiences, and opinions – as seen from behind the scenes working for physicians, all of whom I must add are skilled, talented, and fundamentally understand and most certainly abide by the oaths they all took.

Sunday, October 11, 2009

Day of boredom

Sunday is always a terrible day in news, so boring. The gigantic portion of the world that holds true to any one of the numerous christian or catholic belief systems are at church undoubtedly. The rest of us are dreading going to work tomorrow or trying to squeeze the rest out of our weekends; like myself.

Not to worry though, tomorrow is Monday and that always brings the flood of news that either happened over the weekend or while no one was paying attention.

I wonder what scandal we here in California will uncover this week; will it be more news about the infamous Acorn? Will Schwarzenneger make yet another idiotic decision? Will another body be found in a dumpster? Whatever it is, if you're here in California like myself - you know it will be entertaining, scandalous, exciting or all of the above.

Let it begin

So, it's 3am; I couldn't sleep so I decided that it's about time I get my blog-O-madness going as I have wanted to for quite some time.

Please feel free to tune in for regular updates about all the crazy and insane things I will have to say, the hilarious antics I get myself into and my take on the world today. You will be entertained!
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