Friday, March 31, 2006

Rabies

It appears to be the time of early spring when we begin to see more animal bites. We’ve had two incidents already this week in the office.

The question always comes up about Rabies and whether the individual should get vaccinated.

Here is a brief review:

Rabies is a virus that causes an acute brain infection. It can occur in all warm-blooded hosts, including humans, and the outcome is almost always death. Only a few animals are important for us in the USA as frequent carriers of the disease. The most common include raccoons, skunks, foxes, and coyotes and bats. In addition, dogs can also carry rabies but it isn’t all that common.

The most common way that rabies is transmitted is through the bite and virus-containing saliva of the infected animal. It can be obtained by contact with the eyes, nose, mouth, aerosol transmission, and corneal transplantations.

Once an animal is infected with the virus, it usually takes 1-3 months to start showing signs of infection but can begin within days of infection.

The first symptoms of rabies may only be malaise, fever, or headache, which may last for days. Within days, it may progress to symptoms of brain dysfunction, anxiety, confusion, agitation, progressing to delirium, abnormal behavior, hallucinations, and insomnia. This initial phase typically ends after 2 to 10 days. Once clinical signs of rabies appear, the disease is nearly always fatal. Treatment at this point is usually just supportive.

Disease prevention is entirely prophylactic. It includes giving serum containing antibodies as well as giving the vaccine in the multiple shots. To date only six documented cases of human survival from clinical rabies have been reported and each included a history of either pre- or post exposure prophylaxis.

Dogs, cat, ferrets that are healthy and avail for 10 days observation require no prophylaxis unless animal develops sign of rabies. Then immediately vaccinate and consult public health officials.

Skunks, raccoon, foxes and most other carnivores and bats should be regarded as rabid unless animalproven negative by lab tests. You should consider immediate vaccination.

Livestock, small rodents,and large rodents should be considered individually. Consult your local public health official

Squirrels, Hamsters, chipmunks, rats, Mice, gerbils, guinea pigs, rabbits almost never require vaccination.

* During the 10-day observation period, begin postexposure prophylaxis at the first signs of rabies in a dog, cat, or ferret that has bitten someone. If the animal exhibits clinical signs of rabies, it should be euthanized immediately and tested.

+ The animal should be euthanized and tested as soon as possible. Holding for observation is not recommended. Discontinue vaccine if immunofluorescence test results of the animal are negative

Thursday, March 30, 2006

United Healthcare fines

United Healthcare along with 2 sister companies has been fined by the Georgia’s Insurance Commissioner $2.8 million dollars for delaying payment on as many as 80,000 claims.

This is another tactic for insurance companies to keep more money in their accounts for as long as possible in order to earn interest etc.

The Commissioner also is requiring them to bring their payment policies in line with state laws. They are on probation in Georgia for a year and if they have no further infractions, the fine will be reduced by $500,000.

United Healthcare was fined for similar offenses in years 2000 and 2002. I guess the fines are less than what they make by withholding our money!

Wednesday, March 29, 2006

The Crisis

As 2006 moves into its second quarter, many physicians are facing the worst year of their professional careers and patients will begin facing increased problems with access to care.

Patients are demanding better, quicker and more efficient services; they expect state of the art equipment and the latest technology in diagnostics. Insurance companies and government regulations continually add more burden and red tape to our offices. It takes longer for approvals, prior authorizations, and over-rides on everything we order for what we believe is in the best interest of our patients. Malpractice premiums have increased 10% or more every year for the past several years and other office expenses continually increase.

This all occurs while reimbursements from Medicare, Medicaid and the insurance companies fail to even keep up with inflation, let alone increased costs. Our employees expect their yearly raises, bonuses, and cost of living adjustments as well as their fringe benefits. The bottom line is that physicians are becoming increasingly frustrated and are left with little options. The financial burdens are causing physicians to cease practicing and many will change what they will and will not do.

Many physicians are looking at ownership in other healthcare entities or other investment businesses to survive. Some local physicians are working second jobs at Urgent Care and other facilities to make ends meet.

For your information, the Salary in 2004 for Humana’s CEO was $723,115 with a bonus of $1,247,373 and stock options totaling $24,133,460. The UnitedHealth Care’s CEO, in 2004, made $2,176,973 with a bonus of $5,550,000. He has cashed out $114,552,832 in stock options over previous years and has another $139,598,622 in stock options available.

This occurred while they paid physicians less than Medicare rates for most of our services.

Physicians cannot negotiate fees as a group and cannot discuss options of whether to collectively terminate contracts with providers because of legal issues. This places us at an unfair advantage and continually ties our hands. In addition, insurance companies will not provide us with a complete fee schedule to base our decisions. They only give us a few codes on common procedures. Some of the billing issues were discussed in last weeks postings. There are numerous other problems related to the medical billing system and the insurance industry.

As the current situation and healthcare environment progresses in this manner, more physicians will be limiting what they do and who they serve. It is now at a crisis and things will need to change.

Physicians have met with Sodrel and had meeting with Cochran this morning, but because of personal reasons, he has rescheduled. Connie Sipes is working with us on future dates as well to meet.

Tuesday, March 28, 2006

Trustee Article

There is a new article in the “Trustee” magazine sent to Hospital Board Members. The topic is titled “Trustee and Board Certification: A Future Trend?”

The main point of the article is that strong leadership and continuous learning are inseparable for the survival of hospitals in the ever-changing and demanding healthcare field.

The article stresses that Boards have an opportunity now to set their own standards for continuing education and ensure that trustee compliance is linked to reappointment.

The ending quote from the article states; “In a changing health care environment, the uneducated board will soon be a thing of the past.”

The healthcare environment has progressed very quickly in the past 30 years. Governance of Hospitals unfortunately has not followed the same trend. Excellence in all aspects of Healthcare should include the Trustee level as welll. Floyd Memorial has always encouraged attendance at continuing education functions for Trustees, but it has never been required. There is no routine monitoring of any member's competence, continuing education or their knowledge about current healthcare issues.

The suggestions from the article were as follows:

• Be proactive and make requirements for Board Appointments and reappointments before outside agencies mandate the rules.
• In our case, they recommend assigning responsibility for ensuring competence of Board Members to the County Commissioners that appoint them
• Have a specific budget for Board Education
• Pick high quality educational opportunities for the Board to participate in and make sure they have the resources to do this.
• Be very careful about having some Board Members being extremely well-versed on the topics and healthcare environment and other Board Members without any understanding of healthcare and governance. This compromises the entire Board and possibly the success of the hospital
• Tie in the education topics with issues specific to your hospital.

Again, these changes would be far different than what is occurring now.

Monday, March 27, 2006

Commissioners need to play the game

The balls been thrown into the Commissioners court, but they evidently aren’t wanting to play.

In February, the Medical Staff at Floyd Memorial drafted a resolution asking the Commissioners to increase the size of the Board of Directors to nine members and appoint two physicians.

This resolution was then forwarded to the current Board for approval and support. The current Board also agreed with the proposal and added their support before sending it to the County Commissioners.

In addition to the Medical Staff and the current Board, the Floyd County Medical Society met in early March. They also drafted a letter to the Commissioners asking for the increase in the size of the current Board with the addition of two physicians. The society is also willing to supply a potential slate of names for the Commissioners to choose

The Floyd County Medical Society is the only real legal entity with political ties. Although it has declined in its clout over the years, it was at one time a very powerful organization and could truly influence decisions in all areas of local government and hospital administration.

The hospital administration stated publicly at the last Medical Staff meeting they also would support the change in the Board composition.

With the Medical Staff, the current Board, the Administration, a paid consultant, and the Medical Society all stating the composition of the Board needs to be changed, why are our Commissioners not heeding the advice? Do they really have the best interest of the Hospital and the Community in mind? Will making the changes as proposed appear as if they made a mistake earlier in the year with the reappointments? It certainly isn’t a cost issue because the Hospital actually pays the $300/month Board Member salary.

The next time you see one of your three Commissioners, Chuck Frieberger, John Reisert, or Steve Bush; ask them why they aren’t following the advice of those in position to know what is best for Floyd Memorial and the community.

Ask them why the Hospital is on diversion more now than before the $65 million dollar addition. Ask them why staffing is worse now than before. See if they can give a legitimate answer!!

Friday, March 24, 2006

Legislation

As a continuation of the previous days discussion on payment problems, here are some recent legislative actions and there current status. The Indiana State Medical Association (ISMA) support is listed as well.

Bill: SB 147 Insurance payments to Health Care Providers
Author: Sen. Beverly Gard, R-Greenfield
ISMA Position: Support
• Final Status: SB 147 was signed by both Senate and House leaders and awaits the governor’s signature. The bill places a two-year time limit on an insurer’s ability to take back money it over-reimburses a provider for health care services.
• In addition, the bill places a two-year limit on a provider’s ability to request additional reimbursement for an underpaid claim. If an insurer adjusts subsequent claims to recoup the overpaid amount, the bill would require the insurer to include detailed information about which patient accounts are affected.
• Sen. Gard authored SB 147 at ISMA’s request – a result of House of Delegates Resolution 05-21. It directed the Government Relations staff to seek legislation establishing a time limit on insurer take-backs.


****This next Bill was very important to physicians and they allowed it to die without a vote. This is one of the reasons that Floyd County Physicians dropped the Aetna contract a few years ago. This clause basically states that if the insurance company has the most patients in the practice, then the physicians guarantee to provide services to this insurance company at the lowest rate of any other company.

Bill: SB 124 Health Provider Reimbursement Agreements
Author: Sen. Beverly Gard, R-Greenfield
ISMA Position: Support
• Final Status: Senate Health and Provider Services Committee chair, Sen. Patricia Miller, R-Indianapolis, did not call a vote for SB 124, which killed the bill.
• SB 124 would have prohibited most favored nation (MFN) clauses in provider agreements. MFN clauses require a participating provider to offer the insurer a reimbursement rate equal to or lower than the lowest reimbursement rate the provider offers another insurer.
• The ISMA opposes MFN clauses because they essentially remove the physician’s right to negotiate in the contracting process. If MFN clauses are permitted in contracts, one or two large insurers could dominate the market.
• The ISMA Government Relations staff will continue to educate legislators during the interim regarding the negative impact of MFN clauses on physician practices.

Bill: HB 1382 – Access to Reimbursement Fee Schedules
Author: Rep. Tim Brown, M.D., R-Crawfordsville
ISMA Position: Support
• Final Status: HB 1382 was not heard in the House during the 2006 session and is dead.
• The bill would have required an insurer or a health maintenance organization, upon request, to make available to a provider the insurer’s or HMO’s reimbursement fee schedule.
• While access to these fee schedules is getting better for currently contracted physicians, other physicians who are not contracted and want to sign into a network are not being given access to the fee schedule before signing a contract.
• This practice is another tactic by the insurance industry to restrict the physician’s ability to maintain a practice and provide quality health care to patients.
• The ISMA likely will pursue legislation on this topic again in the 2007 session.

Bill: HB 1097 – Discount Medical Card Programs
Author: Rep. David Frizzell, R-Indianapolis
ISMA Position: Support
• Final Status: HB 1097 was signed by both House and Senate leaders and now awaits the governor’s signature.
• The bill requires health care discount card companies to register with and be regulated by the Indiana Department of Insurance.
• These companies are currently unregulated by the state. Per ISMA’s request, the bill was amended to require the written consent of each individual provider before being included on the list of participating providers.

Bill: HB 1041 – Health Benefit Mandates
Author: Rep. Jerry Torr, R-Indianapolis
ISMA Position: Oppose
• Final Status: House Insurance Committee Chairman, Rep. Mike Ripley, R-Monroe, did not grant a hearing for HB 1041, which essentially killed the bill.
• HB 1041 would have allowed insurers to write health insurance policies that do not include all state-mandated health care benefits. Such plans would have been available to individuals and employers with no more than 50 employees.
• The bill also would have required the insurer to provide written disclosure acknowledging that the policy does not include all mandated health benefits and a list in summary form of those benefits not covered.
• The bill would have required coverage for at least the following:
Newborn and adopted child coverage
Diabetes
Breast, prostate, colorectal and cancer screenings

You can see that although some progress is being made, there are many more obstacles to overcome. This is why it is imperative that our state and national physician organizations continue to aggressively pursue these Bills.

Thursday, March 23, 2006

Billing pitfalls

Yesterday I gave an example of a simple office visit and the requirements for payment. Today, I want to give examples of the “games” Insurance companies play to avoid paying.

Bundling:
This is where insurance companies will attempt to avoid paying for a particular service or procedure by stating it is included in the office visit.
· The example from yesterday was a urinary tract infection. Several insurance companies will deny payment for the Urinalysis and state it is part of the routine visit and is included in the fee of the visit.
· They also will try and do this with CBC’s, EKG’s and vision screens routinely.

Each one of these procedures requires extra equipment, supplies, reagents, technician or nurse time and is separate from a routine office visit. In some cases, the diagnosis cannot be made without these additional tests. Our Coulter machine that performs our CBC’s cost $15,000 and every individual test has a direct cost related to reagents and supplies besides technician time.

If the patient was evaluated in the office and given an order to go to the hospital and have these same tests done, the insurance company would pay without question, but since it is done in our office at the time of the visit, they try to avoid paying.

Allergy shots:
Patients can come in for an allergy shot alone any day of the week and the insurance companies pay for the shots. But if a patient comes in for an office visit to check up on their Diabetes, Blood Pressure etc. we cannot give them their allergy shot on the same day because the insurance company will not pay us for the shot. This means we either give them the shot and do not get paid for it or the patient has to come back on a different day. Neither of these are legitimate from our standpoint.

Annual Female exams:
We also have problems when women come in for their annual Pap Smears and exams. Some insurance companies will not pay for the cost of the Pap smear if we use an office visit code for a routine physical. They claim this code includes the Pap smear. But this same code is used also in men and we certainly don’t do Paps on them. The Pap smear also takes extra equipment, supplies and the specimen has to be sent out for interpretation which we are billed for.

Consults:
If we are consulted to see a patient at the hospital for a specific reason, we bill for a consult fee. If we then order an EKG or other test that we have to interpret or read on the same day as the consult, insurance companies will many times deny this interpretation fee because they state it was included in the consult fee for that day. If we were to interpret do the procedure on a separate day from the consult, they would pay.

Surgeons:
Surgeons have many problems as well. If they attempt to do more than 1 procedure at the same time or on the same day, they get penalized. The first procedure is paid at the accepted charge, the second procedure get paid at 50% and the third procedure at 30%. Procedures after that are virtually not paid for.
· An example is the hand surgeons who have to reattach 4 fingers. It takes the same amount of time, work, precision and responsibility to reattach the second, third and fourth fingers, but the insurance company will not pay the same. You certainly cannot bring the patient back 4 days in a row to reattach the fingers, but it isn’t fair from the billing standpoint. Anytime a physician performs more than one procedure at a time, they are penalized, even though doing these would ultimately save money and reduce patient risk.

These are a few of the billing issues we deal with every day. I cannot think of many other service oriented jobs that are able to do similar things. My auto mechanic can do multiple procedures on my car and I get billed for each. Plumbers, electricians, beauticians, lawyers etc. can all perform multiple tasks for clients and bill and be expected payment for each.

The medical system is broke and needs an overhaul!

Wednesday, March 22, 2006

Office billing

Here is a typical but very simple example of how a medical office bills for services based on the regulations imposed.

We’ll take the example of a 65 y.o. female who comes to the office complaining of 2 days of fever and burning on urination.

She is taken back to the exam room where her blood pressure, pulse, respirations and temperature are obtained.

She is examined and questioned by the doctor who then orders a complete blood count (CBC) and a urinalysis (U/A).

After he reviews the results and talks more with the patient, he writes a prescription for an antibiotic and she checks out of the office.

The billing process involves filing the claim on a specialized form called a HCFA 1500. (See image)

Every procedure that is to be billed has to have a specific code (CPT code) filed on the form. In addition, every procedure (CPT code) has to be associated with an acceptable diagnosis code (ICD-9 code).

If a CPT code is associated with an ICD-9 code that isn’t approved as an acceptable diagnosis for that test or procedure, the claim will be rejected. (Medicare and insurance companies decide if the code you are using justifies what was ordered)

So for the example above, the following information has to be sent with everything in their correct boxes on the form. If something is missing, the claim is rejected.

A routine Office visit has a CPT code of 99213 and corresponds with the diagnosis of UTI that has an ICD-9 code of 599.0

A CBC has a CPT code of 85025 and is linked with the diagnosis of fever that has an ICD-9 code of 780.6

The U/A has a CPT code of 81002 and is linked to the diagnosis of UTI that has an ICD-9 code of 599.0

Since this is a Medicare patient and we do accept assignment, the following would be charged and collected if everything is perfect.

Procedure 99213 (office visit) has an office charge of $70. Medicare only allows $49.79 and only pays 80% which is $39.83. The leaves the patient responsible for $10.07.

The 85025 (CBC) has an office charge of $35. Medicare only allows $10.86 and only pays $8.68 leaving the patient responsible for $2.18.

The 81002 (U/A) has an office charge of $10. Medicare only allows $3.57 and only pays $2.86 leaving the patient responsible for $0.71

So for the example above, if every “I” is dotted and every “t” crossed, and all codes match and the claim is not rejected, the total billed to Medicare is $115.

Medicare says the visit is only worth $64.22 and out of that they are only paying $51.37.

The patient will then be billed for the remainder of $13.96

If anything is rejected, the claim has to be refiled. The patient has to be billed for the remainder and each one of these claims has to be tracked and followed up on if they are not paid.

This claim is simple. But when there are several diagnoses and procedures it becomes much more complicated. Some patients may have Diabetes, Hypertension, Heart Disease, thyroid problems and may get 4 or 5 different lab tests or other procedures done. The process can get very complicated and the codes can be very similar; all contributing to possible errors.

Private insurance companies may have their own set of rules and billing guidelines. They are always eager to deny claims for any trivial reason. We will discuss some other problems in the billing cycle in the coming days.

Tuesday, March 21, 2006

MedPAC calls for increase in Medicare rates

In more recent news by the American Medical Association, there is finally more people understanding the problem and taking steps to fix them. The following is a recent memo released by MedPAC. These are the types of issues that our AMA should be involved to change legislation.


MedPAC calls for Medicare physician payment to keep up with practice costs
Congressional action needed to stop physician payment cut

For immediate release
March 1, 2006

Statement Attributable to:
Duane Cady, MD
AMA Board Chair

"MedPAC's recommendation to update 2007 Medicare physician payments 2.8 percent based on practice costs is plain common sense, and the AMA welcomes the advice. Without Congressional intervention, Medicare payments to physicians will be cut 4.6 percent in 2007, endangering seniors' access to care.

"The AMA is gravely concerned that Medicare payment cuts will harm seniors' access to care. A national AMA survey found that 38 percent of physicians would decrease the number of new Medicare patients they accept if the first in a series of planned cuts went into effect. MedPAC's report found that some seniors may already be having a hard time finding a physician, and impending cuts are sure to make matters worse.

"With nine years of cuts totalling 34 percent now projected by Medicare, we fear more physicians will make difficult decisions about treating new Medicare patients and quality investments. Sixty-one percent of physicians told the AMA they plan to defer purchase of new medical equipment and 54 percent plan to defer purchase of information technology because of multiple years of cuts. When payments are cut year after year physicians cannot invest in technology to improve quality.

"If enacted by Congress, this new MedPAC recommendation will help physicians continue to treat Medicare patients. Every year, physicians must rely on Congress to right the wrongs in the Medicare physician payment projections. Currently, Medicare payments are inappropriately tied to the ups and downs of the economy – not the health care needs of America's seniors.

"Until the physician payment problem is permanently resolved, seniors' access to care will be repeatedly placed in jeopardy. The AMA will continue to advocate for Medicare physician payment based on practice costs so no senior will have to worry about access to care when they need a doctor."

Monday, March 20, 2006

Wall Street Journal letter to the Editor

In some recent news by the American Medical Association, the AMA is asking for more transparency amongst Physicians and Insurance companies because they understand the difficulties and unfair advantage the insurers maintain. This is a letter to the editor of the Wall Street Journal

AMA to Wall Street Journal: Doctors can post fees, but to little effect
February 28, 2006 (published)

The Wall Street Journal
Letter to the Editor

To the Editor:

Scott Atlas' commentary, "Doctors: Post Your Prices" (Feb. 17) sounds simple and reasonable, and, in fact, the AMA has policy calling on physicians and others in the health care system to post their fees. But gone are the days when a doctor posts fees and most patients pay the doctor directly. Now, it's third-party payers – insurers and the government – who really set prices. And too often – it is the physician who doesn't know what he or she will be paid.

In many cases health insurers (many of which have posted record profits) pay what they wish – often as little 30 cents on the dollar. Physicians deal with insurance terms like "bundling," "down coding" and "discounting"– which taken together and roughly translated mean that insurers pay as little as they possibly can. Mega mergers of health insurance companies mean that physicians often have no recourse but to sign up with the biggest health plan in town – take it or leave it. And both patients and physicians often struggle to find out what will and will not be paid for by insurance. Clearly, more transparency is needed from the health insurance industry.

We agree – there shouldn't be a mystery about medical prices, but just calling on physicians to post their fees will not provide many clues to the actual cost of health care. If we want patients to become more prudent purchasers of health care, they need to be in greater control of their own health insurance choices and decisions, and need price transparency from all sectors of the health-care system as well.

Sincerely,

William G. Plested, MD
President-elect
American Medical Association

Friday, March 17, 2006

AMA survey

Here is an example of our AMA (American Medical Association) dollars at work helping physicians and patients! Is this really a worthwhile way to spend our membership fees?

The AMA partnered with The Robert Wood Johnson Foundation on an initiative to reduce high-risk drinking on college and university campuses.

The results of the survey were as follows: Eighty-three percent of the respondents agreed spring break trips involve more or heavier drinking than occurs on college campuses and 74 percent said spring break trips result in increased sexual activity.

Now I ask; does this come as shocking news to anyone?

Did it take a major survey to show these results?

President of the AMA J. Edward Hill MD made the revolutionary statement "These survey results are extremely disturbing because it brings up an entirely new set of issues including increased risk of sexually transmitted diseases, blackouts and violence."

What planet has this guy been on for the past 20-30 years?

Other specific results from the survey were:

• A majority (74 percent) of respondents said women use drinking as an excuse for outrageous behavior.*
• More than half of women (57 percent) agree being promiscuous is a way to fit in.
• An overwhelming majority (83 percent) of women had friends who drank the majority of the nights while on spring break.
• More than half (59 percent) know friends who were sexually active with more than one partner.
• Nearly three out of five women know friends who had unprotected sex during spring break.
• One in five respondents regretted the sexual activity they engaged in during spring break, and 12 percent felt forced or pressured into sex.
• An overwhelming majority (84 percent) of respondents thought images of college girls partying during spring break may contribute to an increase in females' reckless behavior.*
• An even higher percentage (86 percent) agreed these images may contribute to dangerous behaviors by males toward women.
• Almost all (92 percent) said it was easy to get alcohol while on spring break.
• Two out of five women agreed access to free or cheap alcohol or a drinking age under age 21 were important factors in their decision to go on a spring break trip.

• * Based on the wording of other questions in the poll, the AMA assumes reckless behavior is associated with sex and binge drinking. The AMA assumes outrageous behavior is associated with public nudity, dancing on tables/bars and participating in drinking contests.

I’d like to hear from bloggers if anyone thinks this study is a worthwhile way to spend money. Is there not better uses of these dollars trying to change and impact legislation to improve our healthcare environment?

Thursday, March 16, 2006

Taxes and Medical Care

Besides our inefficient, overburdened and illogical payment system for Medical Care in the United States, here is a description of our tax system. It also is extremely illogical and overbearing with few Americans actually understanding the process.

According to the web site truth or fiction:http://www.truthorfiction.com/rumors/t/taxcuts.htm ,this particular example of how our current tax system works cannot be attributed to any known author. But even without knowing the author, the example is very accurate to many Americans way of thinking.

Sometimes politicians and journalists exclaim; "It's just a tax cut for the rich!" and it is just accepted to be fact. But what does that really mean? Just in case you are not completely clear on this issue, I hope the following will help. Please read it carefully. Let's put tax cuts in terms everyone can understand.

Suppose that every day, ten men go out for dinner and the bill for all ten comes to $100. If they paid their bill the way we pay our taxes, it would go something like this:

The first four men (the poorest) would pay nothing.
The fifth would pay $1.
The sixth would pay $3.
The seventh would pay $7.
The eighth would pay $12.
The ninth would pay $18.
The tenth man (the richest) would pay $59.

So, that's what they decided to do.

The ten men ate dinner in the restaurant every day and seemed quite happy with the arrangement, until one day, the owner threw them a curve. Since you are all such good customers," he said, "I'm going to reduce the cost of your daily meal by $20." Dinner for the ten now cost just $80. The group still wanted to pay their bill the way we pay our taxes so the first four men were unaffected. They would still eat for free. But what about the other six men - the paying customers? How could they divide the $20 windfall so that everyone would get his 'fair share?'

They realized that $20 divided by six is $3.33. But if they subtracted that from everybody's share, then the fifth man and the sixth man would each end up being paid to eat their meal. So, the restaurant owner suggested that it would be fair to reduce each man's bill by roughly the same amount, and he proceeded to work out the amounts each should pay.

And so:

The fifth man, like the first four, now paid nothing (100% savings).

The sixth now paid $2 instead of $3 (33% savings).

The seventh now paid $5 instead of $7 (28% savings).

The eighth now paid $9 instead of $12 (25% savings).

The ninth now paid $14 instead of $18 (22% savings).

The tenth now paid $49 instead of $59 (16% savings).

Each of the six was better off than before. And the first four continued to eat for free. But once outside the restaurant, the men began to compare their savings.

"I only got a dollar out of the $20," declared the sixth man. He pointed to the tenth man," but he got $10!"

"Yeah, that's right," exclaimed the fifth man. "I only saved a dollar, too. It's unfair that he got ten times more than me!"

"That's true!!" shouted the seventh man. "Why should he get $10 back when I got only two? The wealthy get all the breaks!"

"Wait a minute," yelled the first four men in unison. "We didn't get anything at all. The system exploits the poor!"

The nine men surrounded the tenth and beat him up.

The next night the tenth man didn't show up for dinner, so the nine sat down and ate without him. But when it came time to pay the bill, they discovered something important. They didn't have enough money between all of them for even half of the bill!

And that, boys and girls, journalists and college professors, is how our tax system works. The people who pay the highest taxes get the most benefit from a tax reduction. Tax them too much, attack them for being wealthy, and they just may not show up anymore. In fact, they might start eating overseas where the atmosphere is somewhat friendlier.

I would guarantee that if every American were given their entire earnings every payday and then required to write out a check to the government on a weekly, monthly or quarterly basis, our tax system would be overhauled in a hurry.

Just as in Medical Care, we have taken the personal responsibility out of the process and Americans have become complacent to what is really happening.

Wednesday, March 15, 2006

Diversion update

For the bloggers asking about updates on the Hospital diversion situation.

Floyd Memorial has been on diversion off and on since the last report. Patients were holding in the ER on both Saturday and Sunday this past weekend. Monday morning the ER was holding 3 patients who were awaiting beds, Tuesday morning the ER was holding ~12 patients and there are 3 on hold this morning.

Attempts are being made to open up other available beds on the floors and work with existing staff. Nurses and other personnel are being asked to volunteer for extra shifts to help cover during this time of the shortage. The flu season has not helped this situation and continues to burden an already overwhelmed system.

Our nurses are extremely conscientious and I have no doubt they will step up to fill the gaps. But in the long run, in my opinion, this is one of the main reasons why so many eventually leave the nursing field altogether.

In addition to the above, our Emergency Room is attempting to implement a new computer charting system during this extremely busy time. This is creating more stress and frustration with the Physicians, staff and patients.

Tuesday, March 14, 2006

Sad but accurate

An economist by the name Uwe E. Reinhardt published a very nice article in Health Aff. 2006;25(1):57-69

One specific paragraph summarized our current healthcare pricing as follows:

Until now, the U.S. health care "market" has been analogous to an imaginary world in which, say, employers offered to reimburse their employees 80 percent of the "reasonable cost" of all attire deemed "necessary" and "appropriate" on the job but, under the contracts negotiated with department stores by the fiscal intermediaries administering this "Clothes Benefit Program," employees had to enter department stores blindfolded. Only months after a shopping trip would the employee receive from the fiscal intermediary a so-called Explanation of Benefits (EOB) statement, explaining how much the employee had to pay for whatever he or she had stuffed, blindfolded, into the shopping cart on that shopping trip. Framed in bright red on that EOB would be the statement: "Pay X amount." X would represent 20 percent of what the intermediary would have judged, ex post, to be "reasonable prices" for those garments in the shopping cart deemed by that intermediary, ex post, to have been "appropriate" attire for the particular employee's circumstances. It also would include 100 percent of the prices charged by the stores for items in the cart that were deemed by the intermediary, ex post, as "not necessary" or "inappropriate" and that were therefore not covered by the Clothes Benefit Program.

Ridiculous though it sounds, such an arrangement closely resembles the current payment system for U.S. health care. It is difficult to reconcile this picture with increasing demands by employers, insurers, and policymakers that patients be forced to act as more responsible "consumers" of health care, a movement now gathering force under the banner of consumer-directed health care.


This scenario is very accurate as to how things occur every day in our current healthcare system. The time for change is here and we as consumers, patients, and providers need to start directing the changes rather than allowing politicians and third parties to dictate them.

Monday, March 13, 2006

Termination of UHC

After several months of negotiations, our group has given official notice to terminate our contract with United Healthcare. Based on the contract, this will become official within 90 days.

Representatives from UHC failed to keep at least two previous scheduled meetings after the physicians cancelled patient appointments to meet with them. During the meeting on Thursday, they basically told us that the rates they are paying are competitive and they didn’t really think we could reach a compromise.

The entire medical industry has to change otherwise patients access to providers will continue to decline. This is only the beginning for our local area.

The following is the letter we handed them before they left our office. We hope that patients and employers will begin to notify United Healthcare of their dissatisfaction and help put some pressure on them.

Friday, March 10, 2006

United HealthCare



United Healthcare is a major insurance provider in this area who consistently underbids other companies to capture more and more business contracts.


They are also consistently one of the two worst payors in the area for services next to Medicaid and Medicare. Many of their fees paid to providers are at or below Medicare levels.


This is done while their corporate profits and CEO salaries are skyrocketing as shown in the following pictures.

We find these salaries to be excessive. If the playing field was level and physicians could work collaboratively to negotiate like other businesses, it would be different. But when we are restrained from fair negotiations, this places the insurance companies at an unfair advantage.




The physicians in our practice have made the difficult decision to proceed with terminating certain contracts with Insurance companies if we cannot renegotiate the terms. Our hands are tied and we have little options other than terminating contracts.

Cost of living increases and our fixed costs go up yearly as we continue to give raises and benefits but have no way of making the Insurance companies increase their reimbursements.

The healthcare climate is worsening for patients and physicians for a number of reasons and I fear it will get even worse before things change. We are probably the first to terminate a major insurance contract, but we will not be the last in Floyd County. Patient access will continue to worsen.

We have elected to inform our patients about our decisions and solicit their help to overcome the problem. Below is a copy of a letter to our patients explaining the situation.

Thursday, March 09, 2006

Classic frustration

Here’s a classic problem we see in the office every day. Humana and United Healthcare are the worst when it comes to problems like these.

CASE:

44 y.o. patient recieved a routine chest x-ray for pre-op evaluation before surgery. The report came back abnormal. The official report read as follows from the radiologist:

IMPRESSION: Abnormal nodular density in the right lung base on the PAfilm. Recommend CT scan of the chest for further, more appropriate,evaluation.

I received this report because I am the patient’s primary care doctor. I did not order the Chest x-ray. After receiving this report, we informed the patient and I told my staff to schedule a CAT scan to evaluate it further and be sure it was not an early Lung cancer.

My staff called Humana who promptly denied the CAT scan. They said the report was not specific enough and they would not approve the test.

So now, as the physician, we are left with telling the patient that their insurance refused approval of the test. We could appeal, wait and repeat the Chest x-ray in a month or do nothing.

This patient was a long time smoker and has a family history of lung cancer. Who in their right mind would choose to wait or do nothing? The Radiologist who read the x-ray felt a CT scan should be done and I agreed, knowing the patient and family history.

These are the problems we contend with every day while Humana and other insurance companies continue to practice medicine without a license or responsibility for these decisions.

We will appeal and eventually get the CT scan done, but it now takes at least one letter and several more phone calls and a lot more staff time all while the patient is left wondering. Who pays for Humana’s decisions? Who should be responsible for the refusal of a test that two independent physicians felt was indicated.

This is one small part of our overall healthcare dilemma that has to be fixed.

Wednesday, March 08, 2006

Note from employee

I've been asked repeatedly why I have been so vocal and placed myself in the path of such venom. The answer comes from cards like the one shown here.



The card above was part of a very nice note sent to my office. This card, along with the emails, letters and and dozens of personal comments I receive, is the reason I speak out. I care about patients and employees and want a long-term successful hospital.

I've not been fitted for my concrete boots yet, but I think a few out there are sizing me up!

Tuesday, March 07, 2006

Newspaper corrections

My intentions were to post some interesting medical information over the next few days, but after receiving several phone calls and emails in response to the articles, I thought I would at least comment on this topic for another day.

I appreciate the Courier and the Tribune’s coverage in the past few days. But there are some inaccuracies in the reporting.
[Doctor's blog takes on Indiana medical establishment]
[The News Tribune - Nursing shortage takes toll on patients]

The Tribune stated “Eichenberger said he can’t remember Floyd Memorial being on diversion one time last year.”

This was reported and published in error and should have read that I could not remember Floyd being on diversion because of nursing shortage one time last year. We were on diversion, but always for lack of beds. This was just an unintentional error in reporting.

The Courier’s article also contained some inaccuracies. I never stated as fact that Clark Memorial was in the red for three years in a row, but stated that “from what we were told”. Our board was given this information when we were reviewing our financials and our budget. We were always being compared to Clark and were led to believe that we were in much better shape than Clark County. If this is not correct, our board was being given bad information. That is another issue.

Physicians as well as others who have worked in hospitals managed by Jewish have reported that the “funneling concept” described is a very common perception. Show us the numbers and eliminate this perception.

Lastly, the comments about the primary care group “basically eliminating the need” are accurate. The group is owned by Norton and if Clark Memorial was not in existence, this group would be able to utilize Norton’s. They may choose to use Clark, but if they are like our office, plus have the additional equipment previously mentioned, then they already have nearly everything necessary to provide primary care and practice their specialties. In addition, physicians from the Norton owned primary care groups have told me that they have been encouraged to direct patients in the direction of Norton’s but it is certainly not required. Their representative stated that 70% are sent to Clark. But in our group, more than 95% of our patients go to our local hospital (Floyd). There is a difference.

Not that any of these are huge discrepancies, but it has certainly stimulated more discussion even among Clark County government officials, physicians, staff and the community. Open dialogue is always good even if it is challenging.

Monday, March 06, 2006

Bill to save Silvercrest Dies

It appears the last-ditch effort to save Silvercrest has died without a vote.
[Bill to save Silvercrest dies]

The article stated the sponsor of the bill decided against bringing it up for a vote. The decision was made because he believed the expense was far too great to keep Silvercrest open.

The Courier reported that it was all political maneuvering and made it sound like Cocharan was sincere in his passion to save Silvercrest but the Republicans were just trying to trade votes for the “Major Moves” toll road plan.

As a member of the committee that listened to all the information presented from the various independent government and private agencies before this decision was made, it was crystal clear that the amount of money being spent for Silvercrest was excessive.

Anyone who actually looked at the reports and data would be hard-pressed to come to a different conclusion. The evidence supporting the closure was very strong.

Turning this into a political game is biased and wrong. Why can’t politicians (republicans or democrats) make decisions based on what is right rather than politically correct.

The bigger question that lawmakers, educators, and society need to decide is whether all these handicapped kids should be mainstreamed. Is integration really in everyone’s best interest or should alternate forms of education and schooling be contemplated?

Friday, March 03, 2006

Article's turmoil

The article in the Courier on Wednesday certainly stirred the pot again. Physicians have been complaining for weeks to administration about the bed and staffing situation. The ER staff and nursing staff had voiced their concerns repeatedly and again felt as if it fell on deaf ears. I, being the most visible and outspoken, have again taken the criticism even though many have made similar comments.

But once it became outwardly public knowledge through the newspaper, then it certainly moved up on the priority list. The article put substantial pressure on administration to address a critical patient care and safety issue that had been known for weeks.

Since I was quoted in the paper, certain people at Floyd are making comments that I am out to hurt the hospital.

This is absolutely false. This bed problem and nursing problem has been a significant issue for weeks and addressed by a number of physicians, staff and Board members. In fact, month after month last year, the Board asked the administration how staffing was going for the new addition and we were repeatedly reassured that it was “on-track”.

Why is it that trying to fix obvious and glaring problems affecting patient care, safety, morale etc is hurting the hospital? Not appropriately addressing the issue is what is hurting the hospital. Again, ask to see the patient satisfaction results. How can the ER ever even attempt to improve scores when this problem continues?

Besides that, I didn’t approach the newspaper. Someone else notified them of the situation probably because they too felt helpless but realized it was a significant problem. The newspaper contacted me and asked specific questions about the situation and about the memo that was sent to physicians. Should I have lied or marginalized the problem to prevent bad publicity? This is a community owned hospital and a problem of this magnitude should be acknowledged and fixed. The County Commissioners should also be addressing this problem or held accountable.

This typical response of never airing the “dirty laundry” is part of the ongoing problem. The problems are real and visible. How people choose to deal with them will be the real question?

If everyone wants the Hospital to be the best, then problems such as these need to be prevented through proactive measures rather than reacting to them when they occur. Pointing fingers at me or anyone else does nothing to solve these problems.

When physicians cannot admit patients to the hospital where they have privileges, it is not good for the patient’s medical care.

Hopefully Monday we can get back to some other health topics and allow this to settle.

Thursday, March 02, 2006

Courier and Hospital Memo

The staffing shortage, bed utilization and diversion issues made front page news in the Courier Journal. [Staff shortage limits Floyd beds]


The memo that this article refers to is shown here.

Without elaborating further, I’ll let the article, the reporters investigation, and the memo speak for itself.

I will say that there is a lot of chatter in the Doctor’s lounge about how the hospital is going to pay for this new addition and all that space with the problems identified here and elsewhere.

Wednesday, March 01, 2006

Floyd-Clark differences

People keep asking why Floyd Memorial is successful when Clark County is struggling. I have mentioned before that Clark County has been in the red for the third consecutive year and in 2005, by about 7 million dollars from what we have heard.

So what are the differences?

1. Clark County is managed by Jewish hospital. Jewish charges a tremendous management fee for the services and then basically funnels patients out of Clark and over to Jewish for the lucrative procedures. Jewish has done this with many outlying smaller hospitals. Physicians refer to these as the satellites feeding the “mother ship”. Unfortunately, when these smaller hospitals become more of a detriment, Jewish will just abandon them. Revenue is not always put back into the hospital.

2. The most important reason for the difference in success between Floyd and Clark County hospitals is the Medical Staff and who the staff is affiliated with or where their loyalty lies. The largest primary care group in Clark County is the Dr. Spalding Group. It has many primary care doctors all in one group. The practice is now owned by Norton Healthcare. The office in Jeffersonville is basically a completely self-contained operation. They provide all of the outpatient tests and procedures that would normally go to the hospital. They have their own x-ray facility, their own lab, ultrasound, CT scan, MRI. They do minor surgical procedures in the office and when patients need admitted, they are directed to a Norton facility. They have basically eliminated the need for the hospital and they have a very large patient base in Clark County.

In addition, there are at least 2 outpatient CT and MRI freestanding facilities privately owned taking the lucrative procedures away from Clark.

There were 5 OB/GYN doctors that quit doing OB at Clark in January of 2005.

The lucrative outpatient procedures are continually lost because Clark County physicians are doing more and more in their offices or in other facilities they own. This leaves Clark with more money-losing inpatients on a percentage basis.

Clark may soon lose a lot of their orthopedic procedures because the physicians are looking at building their own spine/orthopedic facility to perform these procedures.

3. The Clark County government has been much more open to businesses over the years and has allowed numerous facilities to flourish and create competition. Floyd County has not been as open and inviting to businesses and can be readily seen by the disparity in growth between the two counties. Their location to Louisville has also contributed to the growth.

4. Nursing staff and other ancillary support personnel has remained very loyal to Floyd even when salaries and benefits fell behind. They used to feel Floyd was like a family and they stuck with it. But turnover rates have worsened in the past few years and more staff are leaving for other opportunities.


5. The Medical Staff at Floyd has historically been a very tight-knit group and very loyal to the hospital. In addition, most of the primary care doctors and many of the specialists actually lived in Floyd County. The percentage at Clark has been much less. But when you look at the facts and trends in how the environment is changing, you can see that we are becoming more like Clark County in the physician makeup. Our Medical Staff is becoming much more disjointed from the Hospital and learning they can provide services more efficiently and cost effectively if we do it on our own or with other physicians. This is the one area that Floyd County Physicians have been slow to adopt. But it is changing. In the past 10-15 years, here are some of the changes that have occurred:
i. Opthalmology and ENT services have transitioned to private facilities or outpatient surgical centers
ii. Gastrointestinal procedures such as Colonoscopies, Sigmoidoscopies, and EGD’s are done outside the hospital in private facilities
iii. Cardiology procedures like treadmills, nuclear studies, ECHO’s are being done in the cardiologists offices
iv. OB ultrasounds, GYN procedures are being done in the physician office
v. Bone density scans are done in the office
vi. Many CT scans and MRI’s are being done outside of the hospital in private facilities
vii. Neurologists are doing more of their procedures in their offices

These are just a few of the many things that Floyd has lost over the years. Each one of these physicians tried to work with Floyd prior to taking business away, but was repeatedly met with resistance. They did not want the hassles of starting these things on their own, but as they look back, they realize it was the right thing to do.

The Hospital did joint venture recently with the radiology group for the outpatient imaging facility off Grantline road but not without significant conflicts. The joint venture with cardiology is not proceeding, and the joint venture with the surgeons for an ambulatory surgical center is having problems as well. The surgeons are actually looking at doing it without the hospital, but negotiations continue. The OB/GYN group is looking at changing to Clark County or Norton’s as their hospital-of-choice for deliveries and many primary care doctors will obtain privileges at the new hospital in the area when it comes.

The trend is not looking good. I am sure you will see comments from our anonymous blogger that the physicians were greedy and just looking at making money by taking the procedures out of the hospital. I would encourage everyone to talk with any of the physicians in specialties mentioned above and ask them how they had repeatedly tried to work with the hospital and make changes before they made these tough decisions.

Most physicians will quietly transition further away from the hospital without much awareness as very few seek or enjoy conflict. They want what is best for their patients and when they cannot get it, most have found it easier to start new rather than attempt to change the old.

The differences in success or failure is not because of administrations. Most physicians and employees have seen at least 2 administrations come and go at every hospital in the area. Some have seen 3 administrations come and go. It is the dedication and loyalty of physicians and employees that lead to success. Physicians bring in the patients and thus the revenue, without which nothing could be done. How administrations nurture these relationships to continue bringing patients and revenue to the hospital is their most important job. Comparing the trends at Floyd to what has happened at Clark is worrisome.