Diary of a Benefit Scrounger: It's all in your Head

Diary of a Benefit Scrounger: It's all in your Head: Every time I'm in hospital, I learn something. Sometimes the lesson's been very, very hard to learn....
"Don't ever be one of those doctors. If you cannot find out what is wrong with a patient,you have failed, not the patient. Don't ever blame a patient if you can't find out what is wrong with them, blame yourself. Lazy doctors blame the patient. Good doctors listen to them.

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Doubting your patients, judging them, labelling them, is dangerous. But most of all it's cruel. It leaves scars deeper than any surgeon. Yet I've met precisely four people to talk to so far this stay and it was ALL "all in their heads." Unlikely, isn't it.

Repost from Paul Levy's Not Running a Hospital, on Healthcare Costs

Margaret answers Howard Posted: 23 Sep 2011 03:02 AM PDT One of my regular readers threw down the gauntlet after a recent post: Hi Paul.  You are very discerning about the problems we face. This last blog of yours is a criticism of what the President has said.  You have also, rightly in my view, urged caution regarding global payments. What I would appreciate from you is your suggestions for dealing with the rising costs of health care. Howard First, we have to acknowledge that a large portion of the rise in health care spending in the developing countries is caused by demographic trends.  The elderly are living longer and the baby boomers are reaching the age that requires tertiary care. Both groups, too, are incredibly entitled and want interventions that in previous eras would have been unavailable; e.g., knee and hip replacements.  Looking ahead to the next generation, we see an epidemic of obesity accompanied by its friend diabetes, with high cost sequelae like kidney disease, heart disease, vascular disease, and eye deterioration. Second, we have created a medical arms race that feeds on and into these trends.  Whether robotic surgery, proton beam emitters, or smaller devices, manufacturers and investment bankers have learned how to create markets for such inventions that take hold well in advance of evidence of clinical efficacy or cost-effectiveness.  Ditto for direct-to-consumer approaches to pharmaceuticals. Third, we have a regulatory and accreditation system in place for hospitals that focuses on bureaucratic and often picayune "conditions for participation" or "requirements for improvement" that do not address systemic flaws in the way work is done in hospitals. Fourth, there is virtually nothing in the medical education process that teaches young physicians and nurses about the science of process improvement.  Likewise, the educational process virtually ignores the potential value that patients and families have in creating clinical partnerships that result in less harm and greater efficacy. Fifth, there is an appalling lack of transparency in our health care system with regard to clinical outcomes.  Such data as are published are stale.  Ditto for cost and price data that might influence both providers and consumers in their choice of diagnostic tools, therapies, and location of care. Finally, health care is such a large part of our economy that political approaches to these problems inevitably hit the wall of special interests who stand to lose by changes.  The expression, "one person's costs is another person's income," provides a shorthand for the cause of political and administrative gridlock on these items. One could easily conclude from this list that all is hopeless, that the only way to bend the cost curve is to impose administrative fiats that curtail the amount of money available to the providers in the health care system.  Indeed, commenters on this blog have made such a point.  Sure, it might cause some hardship and rationing, they argue, but at least we will start reducing the rate of increase. This is the same argument used by tax limitation advocates in the past:  Starve the beast, and the bureaucrats and politicians will finally be held in check.  By definition, this is true, but it can have major unintended consequences.  Proposition 13 in California and Proposition 2-1/2 in Massachusetts both succeeded in limiting taxes in their respective states, but both began a long downward cycle in the quality of public education and other governmental services. So, Howard, where do we go from here?  First, let's acknowledge that the solution is a long-tailed one.  It will not take place during the period viewed as important by politicians, i.e., the next election cycle.  Neither will it be resolved during the period viewed as important by businesses, i.e., the next financial report.  It will take years, maybe decades. In Jönköping County in Sweden, arguably the world's exemplar in such matters, the learning process took decades -- and with a political and social environment much less combative than ours. In my former hospital, where we had an explicit strategy to be a low cost, high-quality, patient-centered environment, the cultural transformation involved took at least five years.  Even then, we felt we were just getting starting in reaching aggressive clinical goals and eliminating waste in our processes.  I am sure that other industry leaders, like those at Virgina Mason, Gunderson Lutheran, and Ascension, would say the same. But, every journey must start with single steps, and we need to get to work.  Each of the causes outlined above suggests its own remedy.  The variety of causes also suggests that a single, global solution is unlikely to work.  Anyone who says, "All we need is x (e.g., where x is global payments) is barking up the wrong tree.  Incremental change along each front is called for, along with mid-course corrections when that change has unintended consequences. All this only happens with a demonstration of clinical and administrative leadership from those in the field, and from the Boards of Trustees who oversee our institutions.  Too many hospital CEOs, chiefs, and board members think they have "arrived" when they reach their high posts -- and then coast thereafter enjoying the salaries and/or prestige of their positions.  Instead, they have to understand that they are facing the challenge of their lives -- fixing an unsustainable health care delivery system -- and progress will only occur when they move past their comfort range and have the intellectual modesty to learn from their patients and from those in other fields that have been through structural change. In this blog, I have offered success stories in many of the problem areas mentioned above.  I have also offered detailed policy prescriptions where government intervention could directionally make a difference.  As in all other aspects of American life, though, broad and sustained progress will only occur when committed people let their views be known.  It would help if a "barely restrained mob" of patient advocates could find its way to focus on key variables and demand accountability locally and nationally.  But short of that mob, every citizen has right to let his or her voice be heard in their community.  There is no magic bullet that can take the place of that.  As Margaret Mead said, “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has.” http://runningahospital.blogspot.com/2011/09/margaret-answers-howard.html?utm_source=feedburner&utm_medium=email&utm_campaign=Feed%3A+blogspot%2FmJlm+%28Not+running+a+hospital%29

Repost from Survivor Pediatrics- More on the cost of office visits

The Cost of Servicing Your Child

August 31, 2011

WRITTEN BY SUZANNE BERMAN, MD, FAAP

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Written by Suzanne Berman MD

Several years ago, when I took my car in for servicing, I noticed this clever message printed on the back of the mechanic’s invoice:

This simple, honest explanation of my bill impressed me so much that I kept the invoice. More recently, I’ve thought about using a similar illustration for patients who ask, “I don’t understand why my pediatrician’s bill is so high – I only saw the doctor for about 10 minutes!”

Using the auto mechanic’s model, I’ve taken our practice’s actual expenses for 2010 and broken them down by category, as well as percent of our total budget, to give you an idea of where the money goes.

So with apologies to the creator of the automobile piece, here’s what goes into the cost of servicing your child:

Utilities and rent: 10%	We spend a tenth of our budget just keeping the lights on, the telephone ringing, the heat and A/C running, and the rent paid.
Supplies: 9%	Nearly another tenth of our expenses go to supplies, both clerical (appointment cards, copy paper, and pens) and medical (gauze pads, diapers, and casting supplies.) The largest single supply expense we have is vaccines; it’s not uncommon for a busy pediatric practice to have many thousands of dollars in vaccine inventory at a time.
Clinical staff: 13%	Our nurses and medical assistants are busy from open to close – they weigh and measure our patients, draw blood, give shots, answer medical questions, complete school and camp forms, return phone calls, coordinate referrals, talk to the home health agency, refill prescriptions with the pharmacy. All these astute individuals are friendly and talented; we want to keep them, so we try to pay them well.
Receptionists: 5%	Our front office staff answer the phone, verify insurance, check in patients, distribute paperwork, send and receive medical records, mail and fax documents, process co-payments, confirm appointments, order supplies, and more.
Insurance jockeys: 4%	We don’t have “car jockeys,” but we do employ three full-time staff who could be described as “insurance jockeys.” These longsuffering individuals send claims to insurance companies (a big task) and argue with insurance companies when payments aren’t made properly (an enormous task, as it’s estimated that20% of insurance payments are wrong.) They try to keep up with policy changes in the 200+ insurance plans our office sees in a year. They also work with families who need to establish payment plans, need to get insurance, or who are having trouble navigating their insurance plan.
Supervisory staff: 8%	All our other staff have to be trained and supervised. Someone has to approve their mileage forms, overtime requests, time clock totals, and benefits changes. Someone has to negotiate scheduling squabbles, process payroll, conduct staff meetings, plan the office’s Christmas party, write policies (then rewrite them when they’re unclear), meet with vendors, fix the computers when they’re acting up, call a plumber when a toddler accidentally flushes a toy down the toilet, and about 384 other major and minor things to keep our office running. These staff also have associated professional costs, like dues and subscriptions.
Building maintenance: 4%	Keeping our office clean and well-maintained is hard work for the husband-and-wife team who spend several hours 5 evenings a week cleaning, disinfecting, dusting, vacuuming, waxing, touching up the paint, wiping fingerprints from walls, emptying the trash, getting bugs out of the light fixtures, and more. Seasonally, we also pay a landscaping service (to maintain our grass and plantings) and a guy with a big truck (to salt and de-ice our parking lot). This also includes budgeting for major repairs, like resealing and restriping our parking lot every couple of years, fixing leaks in the ceiling, and cleaning up fallen debris after a bad storm.
Specialized physician training: 22%.	This represents the salaries for the pediatricians in our practice and, yes, paying the doctor is the largest single expense in a practice. Much of this goes to the doctor’s personal overhead: Physicians now graduate med school with an average of $150,000 in educational debt.
Capital investment: 6%	We use electronic medical records at our office, so all of our staff have their own computers, and there are computers in each of our exam rooms. Computers have to be replaced every few years, as do other electronics, furniture, appliances, and tools.
Taxes: 6%	The largest part is payroll taxes for our employees and self-employment taxes for our physicians – but also unemployment tax (federal and state), property tax, professional privilege (license) tax, and sales tax.
Insurance: 7%	We pay malpractice insurance for our professional employees, of course, but also insurance on our building and equipment, health/dental/life/disability for our employees, worker’s comp insurance, and some other odds-and-ends premiums.
Fringe pay: 5%	This includes vacation/sick pay, holiday pay, and our company’s contributions to our staff retirement plan.
Wage and hour regulations: 1%	Overtime wages for our employee constitute nearly 1% of our total annual expenses.

When you pay your pediatrician’s bill, your pediatrician certainly takes home a portion of that, but most of it goes to other things to keep the office ready and running. While our practice isn’t necessarily representative of all pediatric practices – and I know from published benchmarks that our practice is atypical in at least a few ways — this hopefully gives a rough idea of where the pediatric healthcare dollar goes.

Suzanne Berman is a practicing general pediatrician in rural Tennessee.

Repost from Kevin MD- Why 10 minutes costs so much

Your 10 minute office visit needs 8 people and 45 minutes of work

by MARY PAT WHALEY | in PHYSICIAN | 101 responses

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I sat at the checkout desk in my practice last week for the first time and as always, it was a revelation.  If you haven’t worked your check-in and check-out desks recently, I highly recommend it.

An insured patient that I checked out was shocked when I said the charge for her visit was $100.  She said, “But he was only in the room for ten minutes!”  I was briefly at a loss for words.  I recovered, we agreed on a payment plan, I made a note on her encounter form for the billing office and she left.

I’ve been thinking about our conversation, and thinking about what that $100 is supposed to cover…

1. First, we scheduled the appointment, which was a work-in, so it took several people to take the message, pull the medical record (paper charts), call the patient to assess the problem, determine the need for the appointment and schedule it.
2. When the patient arrived, we checked to make sure her address and phone were the same, quickly checked her eligibility to make sure the insurance on file was still in force, and asked for a photo ID for red flags.  An encounter form was generated at the nurse’s station to notify her of the patient’s arrival.
3. The nurse called her from the reception area, weighed her, and took her into an exam room to take her vitals, take a brief chief complaint, review the medications she is taking and check to see if she needed any chronic medication refills while she was there.
4. The physician came in to see her, asked about any changes since she’d last been seen, reviewed her history of present illness and examined her. He talked to her about her illness and described a treatment plan for her upper respiratory infection given her chronic health problems.
5. He prescribed a medication for her problem, updated her medication list and made a copy for her to take with her.
6. He marked the encounter form with the level of service and her diagnoses and gave her the form to take to the check-out desk.
7. He refiled the medication reconciliation in the chart, finished documenting the visit, and placed the chart in the bin to be refiled.  The chart was filed, and the encounter form was sent to the billing office.
8. At the billing office the charges and any payment was posted and the claim was filed.  If there was no problem with the claim, it electronically passed through two scrubs and a final one at the payer.
9. If payment was not denied for any of a dozen reasons, the payment would arrive at the billing office and would be posted.
10. Since the patient did not pay at the check-out desk, the patient-responsible balance is billed to the patient.  If the patient pays on the first statement, it has taken 45 to 60 days to receive complete payment.  Since the patient has BCBS, there is a negotiated rate, so the payment will not even total $100.

I know that patients often say “But he only spent 10 minutes with me.”  Checking back with the provider, I find it was typically longer.  Patients tend to underestimate the time as it goes very fast.

The total visit encompassed the work of the phone operator, the medical records clerk, the triage nurse, the check-in person, the nurse, the doctor, the check-out person and the biller.  It took 8 people, and at least 45 minutes of work to make that appointment happen.  Plus, that visit had to help pay the expenses for the rent, the utilities, malpractice insurance, medical supplies, computers, phones and janitorial services.

The practice, the patients and the overseers of healthcare want each visit to be non-rationed, safe, high-quality, error-free, holistic, pleasant, clean, accurate, efficient and reimbursable.  It’s what we all want.  And it ain’t cheap.

Mary Pat Whaley is board certified in healthcare management and a fellow in the American College of Medical Practice Executives.  She blogs at Manage My Practice.

The Declaration of Insurance Independence

This excellent blog set contains a lot of techno and healthcare management jargon, but it makes powerful point about how much $$ is going to the care and feeding of the insurance system. Time to toss the claims forms into the Boston Harbor! In spirit, of course : -)
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The Declaration of Insurance Independence  (part 1)
"Dave Chase is the founder and CEO of Avado, a TechCrunch Disrupt NYC finalist. Previously he was a management consultant for Accenture’s healthcare practice and was the founder of Microsoft’s Health business. This is Part I of a two-part post. You can follow him on Twitter @chasedave."

" Protesting Healthcare Taxation With Bureaucratization
The summary of the Declaration of Insurance Independence is as follows:

Healthcare’s perverse incentives and an accompanying stifling bureaucracy driven by encumbering day-to-day healthcare with insurance has caused hyperinflation that is crushing family, employer and government budgets and holding back job growth. This must be stopped. Citizens and healthcare providers are doing exactly that, however counter-productive insurance regulations are impairing the ability to expand upon health plans shown to reduce costs by 40% or more.
We, therefore, declare that:

• the United States are, and of Right ought to be Free and Independent of insurance and self-sufficient in accessing day-to-day healthcare;
• that they are Absolved from all Allegiance to insurance bureaucracy;
• and that all insurance connections involving the purchase of day-to-day healthcare, are and ought to be totally dissolved;
• as Free and Independent States they have full Power to explore the range of more effective ways of accessing day-to-day healthcare, and to do all other Acts and Things which Independent States may of right do. "
  

part 2: Declaration of Insurance Independence (Part II): Unleash The Health IT Startups
http://techcrunch.com/2011/07/04/declaration-insurance-independence-ii-unleash-health-startups/ 
" More Time Spent with Patients Translates to Better Health Outcomes and Less Time &
Money Wasted
Interestingly, in the transformative models described earlier, doctors consistently tell me that half to two-thirds of their patient interaction time doesn’t need to be face-to-face (the legacy insurance reimbursement model requires face-to-face appointments for the doctor to get paid). They can deliver high quality medicine without being in the same room as them. By spending less time on insurance bureaucracy, they are able to spend 2 to 8 times more time with patients and still make a reasonable living. These longer appointments aren’t simply a luxury. They’ve demonstrated they can save money and improve outcomes. In the legacy model, a typical 7-minute appointment only allows the doctor enough time to address one symptom with limited time to address the underlying issue."

Thanks, Dave Chase, for this inspiring, call-to-arms salvo!!