Thursday, March 08, 2007

Oh, you're paying for it? In that case... : Revisited

I invited the blogger at Joust the Facts to weigh in on this post since I remembered him posting on similar topics, and since he's someone who has to deal with this firsthand. He was kind enough to reply. His reply is in the comments box at the original post, but I think it warrants a post of its own, especially since some of it was surprising, at least to me:

Thanks for the invite, Kathryn.

I do have something worth adding to this discussion, possibly. I'm an orthopaedic surgeon, and I'll be the first to admit that my prices are artificially high. But they're not high in order to milk the system; they're not high so I can "get rich quick and retire early"; they're not high because I have an inflated sense of what I do.

I'd be more than willing, happy even, to cut my "usual and customary fees" by 40-50% if someone would simply guarantee me that I'll be paid - by all insurers - what I bill. I'm not. That fact makes my practice's gross income extremely unpredictable, as it's dependent each month on what the insurance mix was for the cases we did.

For some of the complex reconstructive procedures that I do on shoulders government payors and the HMO's pay me, on average, about 24-25 cents on the dollar. You read that right.

As a result I need to keep my fees artificially high because I need the occasional "good insurer" or workman's comp carrier (the private ones pay fairly well) or wealthy self-payor to make up what I lose on the government contracts. I've often said that if everyone paid like Medicare my four physician Ivy League trained group would be out of business. And we would, unless we started practicing impersonal high-volume medicine, which we don't.

So keep pushing for Medicaid, Medicare and HMO's to hold down physician payments and you'll continue to see a warped and unaffordable system for those not so privileged.

You may be interested to know that at high profile medical centers, like the Mayo Clinic, and for in-demand large city physicians most insurances aren't accepted. You pay cash, and if you want some of it back you submit your bill to insurance for re-imbursement. I have a friend from medical school who practices internal medicine in Washington DC who takes no insurance. As a result, he gets what he bills.

This may or may not be related, but it should tell you a little bit about where I'm coming from in this discussion. It took me a long time to realize that our bookstore was never going to survive if we didn't take into account people who wrote bad checks or otherwise managed to take stuff off the shelf without paying for it, or otherwise cost us money through no fault of our own (placing a special order and then not buying the book can hit a small bookstore very hard; more on that someday). It was a hard lesson to learn. It goes against my idealistic streak and a sense of justice to ask honest people to help pay for what dishonest people do, but for the life of me I can't see any other way to do it since we must pay for inventory regardless of what happens to it. We are always working on ways to minimize what dishonest or heedless people can do to us (and by extension our honest and more considerate customers), but the fact remains that every now and then we cross paths with someone who manages to make us bleed financially, and that has to be written into the business plan.

1 comment:

johnG said...

This is eye opening. Thanks for publishing it. Of course, scary. We are blessed with a state system for our parents that is miles beyond the local elite hospital.

Our friend's 94 year old mother was told to wait over the weekend until Monday with her fractured wrist at the elite hospital. My father tried the emergency room at the state system and was seen first class all the way through.

A lot of the state hospital's success has to do with attitude. You won't find a negative face in the place. Not sure how they engender that caring attitude, but it's pervasive. Perhaps that's the fundamental key to good care.

But the question of a good national system remains. If we had a healthy national political scene/MSM, we could debate and examine the health care system. Plan on that not happening.