Some Doctors Letting Patients Skip Co-Payments

NY Times ^ | December 27, 2003 | MILT FREUDENHEIM

[neverdem]

For years, health plans have sought to control medical costs by negotiating fees with a group of preferred doctors and requiring patients to pay extra for going outside the network. But some doctors and clinics - eager to help hard-pressed patients or calculating that it can benefit their business - have begun to foil the cost-control efforts by waiving those extra charges.

The move by these providers to dispense with collecting what are known as coinsurance payments comes as employers and insurers try to discourage overuse of health care by making patients pay more costs from their own pockets. But those efforts - and the squeeze on doctors as health plans shrink payments for in-network care - are generating resistance, experts say.

Health plan members are "going out of network for surprisingly expensive medical services,'' said Tom Farley, who audits managed care plans across the country for the Towers Perrin consulting firm. That behavior suggests "some sort of tacit agreement between the provider and the patient to not bill for some of those out-of-pocket expenses,'' he said.

Dr. Michael O. Fleming, president of the American Academy of Family Physicians, said that doctors' efforts to find ways around the insurers' cost-control strategies are "a reaction to the ratcheting down of managed care fees.''

Doctors are waiving coinsurance payments for several reasons, analysts say: to recruit patients who would otherwise go to doctors on a health plan's preferred list; to help people struggling with the cost of care, and to reduce their own costs for processing insurance paperwork and dunning patients who are slow to pay.

These doctors can afford to pass up the payments because the out-of-network fees they collect from insurers often are higher than those they would collect as members of a health plan's network.

Dr. Herbert Dardik, chief of vascular surgery at Englewood Hospital and Medical Center in New Jersey, scorns collecting co-payments. "I look at it as a demeaning process,'' he said. "I tell my secretary upfront, if there's any issue, just forget it.''

While most doctors still work within managed care networks, waiving patients' payments appears to be most prevalent in the Northeast, South Florida, the West Coast and the upper Midwest - "areas that are saturated with managed care,'' Dr. Fleming said.

In 2003, more than half of workers faced co-payments of 30 percent or more of the fees charged for visits to out-of-network doctors, according to a September report by the Kaiser Family Foundation. The average out-of-pocket costs, including co-payments and other charges, for employees of large companies doubled in the last five years, to $2,126, and are expected to jump another 22 percent next year, Hewitt Associates, a benefits consulting firm, reported recently.

From the health plans' perspective, moves by providers to waive the payments are "exactly what managed care plans are supposed to protect against,'' Mr. Farley said. "The physicians can go back to practicing without constraints,'' he said, for example ordering more tests and procedures.

For out-of-network care, doctors at the Alliance Surgical Group in Morristown, N.J., ask patients to pay any deductible owed under terms of their health plan, a sum that can be as much as several thousand dollars, according to Dr. David Ward, a member of the group. But they do not press for payment if a patient cannot pay a follow-up bill for 20 percent or 30 percent coinsurance. "The deductible could be the whole bill,'' Dr. Ward said. He does general surgery and specializes in bariatric procedures for people who are obese.

Not surprisingly, patients are pleased. "I was amazed that these doctors do not come after the patient demanding the uncovered costs,'' said Lauren Dasylva, one of Dr. Ward's patients, in a statement she posted on a patient support Web site. "I think that is a testimony to why they do this surgery, I am convinced that they have a heart.''

But patients who choose an out-of-network plan run the risk of paying more than if they selected one of their health plan's preferred providers, said Randy Kammer, a vice president of Florida Blue Cross and Blue Shield. "There is no obligation for an out-of-network physician not to balance bill,'' she said, using the term for collecting charges in excess of those approved by the health plan.

Regularly waiving co-insurance payments or co-pays _ the $10 or $20 payments many plans impose for office visits - is against the rules in the government Medicare and Medicaid programs. A few states - Colorado, Georgia, Nevada, South Dakota and Texas - also prohibit the practice for patients covered by commercial insurance, according to Dennis M. Barry, a Washington lawyer who studies health care reimbursement issues.

Colorado and Georgia also forbid advertising the waivers to attract business. A handful of states have banned the waiver of co-payments and deductibles by dentists and chiropractors. And Ohio prohibits routine waivers of co-payments, but not deductibles, by physicians, pharmacists, psychologists, physical therapists, nurses and optometrists, according to a survey published last month by Mr. Barry and Lori Mihalich.

Waiving payments for indigent patients or to placate those who have complaints about their treatment "should not pose legal issues,'' however, they said.

A policy statement by the American Medical Association's Council on Ethical and Judicial Affairs says that "physicians should forgive or waive the co-payment'' if it would pose "a barrier to needed care because of financial hardship.'' The statement warns, though, that "routine forgiveness or waiver of co-payments may constitute fraud under state and federal law.''

[neverdem]

Third party payers have made a complete mess. If a doc feels compelled to commmit charity, then the doc may be an accomplice in fraud.

Happy New Year

[neverdem]

PING

Happy New Year

[ThinkDifferent]

Third party payers have made a complete mess.

Indeed. That's the entire health care problem summed up in 8 words.

[Tennessee_Bob]

Something else that hurts the patients and the costs is the prescribing of the latest and greatest meds. The drug reps are pushing the latest stuff, and there's no mention made (or so it seems) of formulary status, cost, or co-pay for the script.

I think if there was more awareness of the patient's pharmacy plan (and I blame that on the patient, not the doctor) and more concern about the cost of the med to both the patient and their plan, we'd see a reduction in the costs. Of course, once that happened, the drug companies would just adjust their AWP, and make the money back again.

I work for a pharmacy benefits manager, BTW.

[hocndoc]

Thanks for reminding me one of the major reasons why I closed my office.

For Family Doctors, if we don't collect at the time of the visit, the $10 to $30 co-pay can cost more to collect than it's worth. On the other hand, it can really add up.

It's amazing how many people go to the doctor without their wallets.

[markman46]

I always pay what ever the copay is, Yes I do believe that people leave their wallet's at home or in the car. and I work in the industry, but the capped Dr's get that nice monthly check whether they see the patient or not. course when you can only spend 5 Min's on each patient, i suppose that is not a good deal either.

[dawn53]

I worked for an endodontist for many years.

I was always amazed that folks would show up with no money, no credit card, no insurance, and no check.

A root canal can be an emergency, but to waltz in, with no intention of paying and expect the dentist's service was beyond my comprehension. Try going to the register at a local department store with a basket of goods, and saying, I forgot my wallet.

Unfortunately, instead of the old-fashioned way of collecting the money after the work was completed. We had to resort to collecting money before the patient was seated.

[hocndoc]

The only "capped" plan I ever participated in was Medicaid (at $3 per patient per month), since that was the only way possible. I cringed when I heard a colleague say, "They're paying us *not* to see the patient."

I've never figured out a way to spend time I felt was necessary with patients and get paid enough to cover more than the office overhead for the time.

We tried to collect the co-pay before the service for the flat fee plans, but for Medicare, it was harder.

[bonesmccoy]

What the heck do YOU care what I write as a physician?

Furthermore, if I choose to write for a medication with lower dosage, fewer side effects, tastes better, and is less filling; why should an executive working for your company be in a position to lecture a board certified physician about what I'm supposed to prescribe to a patient that I know, I examined, I diagnosed, and should be able to treat as quickly as possible?

[bonesmccoy]

I am also a physician. These capitated contracts are almost universally controlled by a limited board of directors of subspecialists.

You appear to be a family practitioner or internist and are being capitated.

You should know that my research indicates that "sub-specialists" are paid well OVER the RBRVS rate. That means your fees are being usurped by the sub-specialists. In addition, many physician networks are lying about their accounting.

We have reviewed many hospitals (supposedly non-profit) and their associated private physician groups.

In various California counties, including Los Angeles, San Bernardino, Riverside, and San Diego, it is possible for a physician to participate in a Blue Cross of California or Health Net Medi-Care or Medi-Cal contract.

However, in the County of Orange, it is NOT possible for ANY primary care physician to be paid under a fee-for-service system. This totally decouples the services from the patient-physician relationship.

Because the hospital risk pools are so large, there are hospitals with substantial off-shore bank accounts, including one prominent chain with a large fund in Bermuda where 75 million dollars of funds appears to be pooled.

Ironically, while the PCP's are being asked to accept 3.50 per month for a person's life, hospital and physician network executives are being paid millions per year.

Do you belong to a private physician network? If so, which one?

If you are in the State of California, there is a strict Business and Professions Code which clearly states that only Knox-Keene licensed corporations are permitted to manage risk pool funds. However, in many counties across Southern California, there are privately held corporations that are NOT Knox-Keene licensed insurance companies, yet appear to be illegally managing medical/health risk pools.

Please post more... I want to get the word out to Freepers about the abuses in the healthcare system.

These abuses are jacking up the cost of care artificially so that liberal health care executives can pad foreign bank accounts and ruin the freedoms others fought for.

[bonesmccoy]

our group will not permit the patient to be seen unless the co-pay is paid up front. We accept cash, credit card, ATM, checks. We routinely have bounced checks from people.

These costs have added up, but we call the family and ask if we can use a charge card instead. We bill the co-pay and a penalty for bouncing the check (equivalent to the fees imposed by the bank).

[CurlyDave]

Furthermore, if I choose to write for a medication with lower dosage, fewer side effects, tastes better, and is less filling; why should an executive working for your company be in a position to lecture a board certified physician about what I'm supposed to prescribe to a patient that I know, I examined, I diagnosed, and should be able to treat as quickly as possible?

Amen to you. I have had to fight tooth and nail to get the one drug which does not cause excessive side effects in me. I have had to "try" others for months just to prove they didn't work as well, and then every couple of years my employer shuffles us all off to a new plan and we have to start all over again.

I have offered to co-pay more but the damnable insurance company refuses a cost-neutral solution, insisting that they know more about what drug I should take than I or my Dr.

[drlevy88]

You could just eat the whole cost of the Rx. Then the doc can prescribe whatever he or she wants. It's the golden rule, whoever has the gold makes the rules.

[garandgal]

What the heck do YOU care what I write as a physician?

Thank you for that! I have been told several times that my insurance will not pay for a prescription because "WE" (who the heck is WE?) feel that XYZ drug is more appropriate.

First of all, I didn't go to the insurance company to be diagnosed...I went to my DOCTOR; so why is the insurance company involved in deciding which drug is "appropriate"? Secondly, they think we are too stupid to realize that the reason one drug is prescribed over another has more to do with under the table kickbacks than the drug's effectiveness.

Insurance companies are going to be the downfall of the wonderful health care that we have enjoyed in this country. What started out as a nice cost-sharing idea has devolved into a nightmare...due to greed and avarice.

[hocndoc]

Actually, I'm in Texas, and in April, I closed my office (private solo practice - walkin urgent care with some family practice for the last 6 years after 4 years in old fashioned cradle to grave family practice with OB during which I joined 6 other docs in a partnership). I'm not a good business person and the complexity just finally got too much - and my employees started changing jobs for more money but fewer benefits. When what I thought of as my "family" started leaving, I couldn't justify working so hard for so little money.

Now, I'm doing a lot of political work and volunteer testifying and visits to State agencies and hearings. I need and love to be a doctor, so I'm working as a locum tenens with a couple of docs and trying to decide "what I want to be when I grow up." My husband supported us for the last two years while my practice floundered, so I'm taking the opportunity to try to work at changing the things I've griped about for the last 10-15 years.

Those obscene salaries and benefits for the insurance company execs are a pet peeve. How can Dr's fees remain stable for years, when the CEO is making $ 2+ Million a year? (average is $1.74 million salary plus benefits)
http://www.insurancetech.com/utils/printableArticle.jhtml?doc_id=14705473

[hocndoc]

I get calls and letters from my own insurance company suggesting cheaper meds to substitute for what my doctor and I have decided is the best for me. (For restless leg syndrome, they think I should take amytriptiline, for instance. Would you want your family doctor to take this med every night, or how about the driver in the next lane?)

I willingly pay a higher co-pay, but I know many patients can't afford the same, or high co-pays for multiple drugs. But, on the other hand, new, once a day or shorter-course meds are better for the patient's health and the patient is more likely to take them as directed. Most of my decisions are based on the side effects as well as the desired effects. If we harm the patient by our treatment or his treatment is insufficient, the costs will be higher in the long run. And, as low as physician reimbursement is, the extra office visits (or Lord forbid, a hospital stay) will cost much more than the higher-cost drug.

I finally figured out that the way we were trained, with 36 hour shifts and on-call ever 2 or 3 nights, taught us to think differently from nurses, nurse practitioners, physician assistants and insurance bean counters: we think of what could go wrong, what will happen at 2 AM, and the worst that could happen or what will result in a page during dinner or in the middle of the night, and try to plan accordingly.
Insurance companies require doctors to authorize refills and scripts, so why not let us make the diagnosis and treatment plan, as well?

[garandgal]

Just FYI...I live in one of the "insurance capitals" of the country. I noticed an article last week in the business section about executive movement within a particular company...a major group health provider.

Get this...the "executive vice presidents" of departments...not entire divisions...simple departments (as in marketing, advertising, etc.) are making $900,000 per year. I am particulary appalled about the V.P. of marketing...I mean, how hard is HIS job. "Buy our outrageously priced insurance, or your children may die of cancer because you have no coverage." V.P. of extortion would be more appropriate.

[cajungirl]

Doctors are demonized for wanting their patients to be able to not pay a copay in order to decouple the relationship and to serve the financial needs of the insurers. Doctors are thought to be criminals for wanting to prescribe a more expensive drug by implying they do it for some kind of kickback. The above are lies and distortions to deskill the doctor, put the insurer in charge and hurt patients more than they know. It sickens me. And most patients go right along with the lie and the distortion. We are losing something precious here.

[MarkL]

Something else that hurts the patients and the costs is the prescribing of the latest and greatest meds. The drug reps are pushing the latest stuff, and there's no mention made (or so it seems) of formulary status, cost, or co-pay for the script.

However, this is a two way street... Sometimes, the insurance company will only give full coverage to certain, less expensive drugs that, while similar, will not actually take care of the problem...

For instance, my insurance company would cover the generic of Tagamet (Cimetadine), but not Prilosec. I was on Tagamet for over a year to treat an ulcer. The Dr suggested that I try Prilosec. I was on it for 1 month, and I've been free of the ulcer for nearly a year. However, while the cimetadine would only cost me $15 for a month's Rx, the Prilosec cost me $80.

Another terrific example is a treatment for Crohns disease. The medication that my Dr perscribed was Pentasa, which is similar to Sulfasalazine. The problem is where the medication is delivered. Due to my Crohns disease, Sulfasalazine really isn't effective, since it delivers the drug in the stomach, rather than the intestines, which is where Pentasa delivers it. A 30 day supply of sulfasalzine is $15, since it's on the list... A 30 day supply of Pentasa is $115.

While some Drs do perscribe the "latest and greatest" drugs, just because they are newer, in some cases, they just happen to be the right drugs for the condition.

Mark

[MarkL]

You could just eat the whole cost of the Rx. Then the doc can prescribe whatever he or she wants. It's the golden rule, whoever has the gold makes the rules.

There is a contract between the insured and the insurer. If they agreed to perscription coverage, it should be up to the Dr to decide which medication should be perscribed. Often times, the insurance companies will update their list of "approved" medications with no warning, or changing the co-payment mid-term.

It's happened to me on more than one occasion.

Mark

[drlevy88]

However, while the cimetadine would only cost me $15 for a month's Rx, the Prilosec cost me $80.

Annoying if you have to foot that bill yourself, but converting that into a "tax" comes out to $2.67 a day.

[Imal]

When it comes to my health, I'll choose an M.D. over an M.B.A. every time.

Call me old-fashioned.

[NMFXSTC]

While "part" of what you state here is true, there is more than ample over-prescribing and fees that inflate the cost of health care.

I believe AMA and the medical community as a whole still code the common cold as a viral infection...correct? Antibiotics (however generic the prescripion) are empty bullets...correct? Decongestants and expectorants are antagonistic (generally)...correct? In the absence of clinical findings (severe rhonchi or rales) a chest X-ray is not indicated...correct? Yet those regmens are quite common place and seem to justify an esacalated RVS fee...correct?

A simple clean laceration, say 1.5 cm, not involving vessels, nerves, or skeletal tissue and easily closed with interrupted skin sutres is routinely accomplished by taruma techs...crrect? Why, then, the massive increase in cost is an MD/DO spends five minutes and half a dozen 4-0 sutures?

Yes, we have escalated the cost ourselves...it cannot all be attributed to insurance CEO or CFOs...the docs have to take a lot of responsibilty for this as well.

[stopem]

I too am in Texas and I own and operate a medical billing service and my husband is a Pharmacist.
We owned a Pharmacy in Corona Del Mar, maybe the Doctor from California knew of our Pharmacy.

Point is it is my responsibility to make certain that my clients are performing under their contracts with insurance companies.

In Texas it is fraud to not collect copays, deductibles, etc.
Whenever any client tells me that they will waive copays I drop them because I am not about to go to fed prison for them. I am surprised at the attitudes of the responses.

I prefer that when I negotiate a contract for my Provider that is my client that he abide by the terms of the contract.

As to prescribing experimental RX's if the ins carrier won't pay for the experimental drug than why would you prescribe something unless it would save their lives, for a patient who has to cover the costs out of pocket if in some cases another drug may be sufficient?

Point is in the "good-ole-days" the Physician would get quite a lot of perks for prescribing certain Drugs. I don't believe that is allowed any longer is it? It was interesting as a co-owner of a Pharmacy the pattern of certain Doctors to prescribe certain drugs all the time.

Doctors should of course prescribe what is best for the care pf their patient but should see if there is a cheaper alternative drug.

I blame insurance carriers for the healthcare crisis in our Country right now. It costs us a lot to process claims and than carriers like United (which is the worse) will play their stall tactic games after we submit and we wind up having to file again or appeal.

The Physician in California, recently I read were illegal aliens are causing most of the problems with healthcare, emergency rooms and Medi-Cal, instead of not providing Medicaid to these patients Schwarzenneger will CUT The reimbusement rate they will pay Doctors who see these illegal alien patients. What is your opinion about that?

Recently a senator suggested the solution is to first round up all illegals and deport them to whereever than to protect the borders from them flooding back in and than allow some sort of small worker program. I couldn't agree MORE!

[Tennessee_Bob]

Furthermore, if I choose to write for a medication with lower dosage, fewer side effects, tastes better, and is less filling; why should an executive working for your company be in a position to lecture a board certified physician about what I'm supposed to prescribe to a patient that I know, I examined, I diagnosed, and should be able to treat as quickly as possible?

You're absolutely right, Doctor. That patient of yours should be able to fill any script you write with no issues at all. What should we set the copays at? Five dollars for a 90 day supply? What should the premiums be? Maybe thirty dollars a month?

Better yet, let's get the government to subsidize it all, that way, no one has to pay anything for anything at all!

Isn't that what Hillary was aiming at?

And actually, your patients can get any medication you write for, with no qualms from the pharmacy benefits manager, provided they're willing to pay the out of pocket cost for whatever it is.

However, whenever we give them that answer, and let them know that the Zocor script you wrote will cost them $600 for their 90 day supply with no benefit, suddenly, there's a change of heart about that medication.

Far be it from me to question the wisdom of a doctor. After all, these are the folks who have told me, "the medication has a generic name, therefore, there is a generic available." That would also explain why I see life threatening scripts written - minor things like viagra and nitrodur or nitro tabs.

As I was saying, if the patient had more awareness of his plan, he'd make sure the doctor was writing his maintenance med scripts for 90 day supplies with refills for one year. He'd make sure his doctor's office would call in for prior auth (you wouldn't believe how often I hear "my doctor doesn't do that," my unspoken response is "find another doctor").

The PBM isn't stopping the patient from filling whatever they want. However, if it goes beyond what the benefit that the patient chose offers - then the patient has to pay.

As far as the executives making those decisions - they're all board certified physicians and pharmacists. Not that I ever see them - people with letters after their last names circulate on a much higher level than I do.

[Kozak]

I am a partner in a private ER group in Wisconsin. We are contracted with 2 hospitals in the same system. Our reimbursement is locked in to a percentage of the Medicare reimbursement for the HMO patients ( our percentage of HMO patients is rapidly increasing). So, while our reimbursement has been falling as medicare "balances" the books by cutting physician reimbursement, the HMO has jacked the rates they charge by about 30% in the last couple of years making for a very tidy profit. Meanwhile they are shutting down oall their walkin urgent care, channeling the patients en mass to the ER which is understaffed and too small for the load. Oh yeah at the same time threatening our contract because of poor patient satisfaction data. I need to hang on for aboput 4 years, and then I plan on a major career and lifestyle change......

[PistolPaknMama]

more awareness of the patient's pharmacy plan (and I blame that on the patient, not the doctor)

I have private health insurance with Blue Cross. $200 per month that pays for nothing. Prescriptions aren't included, but I am very quick to tell a doctor that I don't have a prescription plan.

There are older meds out there that still do the job without paying a premium for the latest greatest (and most expensively advertised) pill. A gastro doctor prescribed me a new drug at $3 per pill..$90 per month. Of course, you don't know this till you get the prescription filled. When I complained we went to Tagamet for about $17 a month.

[John W]

The John W Health Plan:Medical services to be paid entirely by the consumer.Therefore no insurance and no premiums.However,services and drugs to cost what we end up paying now as copays,deductibles and our 10-20 % of the total for the bigger ticket items.Our pediatricians here in Indiana might have to get by with an outdoor instead of an indoor pool,but,I like my plan.

[manic4organic]

I own my own biz so I pay for my own insurance 100%. My family can only afford a catastrophic plan, so we end up paying at the time of the visit. We usually go to a Doc-in-the-box nearby for most minor health problems and receive decent care. The doctor usually notices what bad insurance we have and gives us free samples of medication just to be nice. Also, they have on most occasions sent me a refund check later for overpayment.

I think if we eliminated Medicare for all but the destitute and got the insurers out as middlemen, we could all afford good insurance coverage. Problem is, people think they should only pay $5 or $10 for an office visit, when at the same time they're paying out the you-know-what in premiums every month.

[codercpc]

In Texas it is fraud to not collect copays, deductibles, etc.

I have worked medical billing (coding/auditing) for 10 years, and I am 99% sure that this is not a state crime, but a federal one. If a physician contracts through the Medicare program, they agree to follow their rules for their whole practice. One of those rules falls under the Stark Amendment which states it is illegal to "entice" a patient to come in for service, basically.

By waiving copays, and or deductibles, you are enticing the patient. I am under the assumption,(this may be a State law in Wisconsin) that the only legal way to waive someones payment of Medical care is to basically deem them a "charity" case. You have to show a "good faith effort" to collect, and unless it would be more expensive for you practice to try and collect than the amount in which is owed, you must bill or charge them. You can also have your patients claim "charity care" by demonstrating a financial need. This is usually done by having them fill out a form with their income, debts, etc.

Without either proving a financial need on the part of the patient, or a financial hardship of collecting on the part of the practice, writing off co-pays and deductibles is a Federal crime for any physician that participates in the Medicare/Medicaid programs.

[bonesmccoy]

Your story is the precise reason that Pharmacy Benefits companies and Physician Networks should be banned from handling risk pool dollars from HMO contracts.

Either health insurers manage risks or not.

If not, they need to remove their products from the market.

HMO plans essentially shift the entirity of the risk to subcontracted companies, like a pharmacy benefits manufacturer.

The "PBM"s capture a "capitated rate" from the HMO insurer, just like the physician network or IPA (which contracts the doctors).

In my opinion these networks need to prosecuted under RICO law and, in fact, the US federal courts just permitted such challenges after 10 years of pleading by primary care doctors who care about freedom of market.

[Timm]

As if we needed more evidence of the over regulation of medicine, this article describes efforts by doctors to lower the price of service to their patients, to attract business. Yet, it's a crime. A crime! What if doctors just competed openly on the market, like veterinarians? What if the supply of doctors weren't so closely controlled by the AMA and its associated certification bodies? We'd find service available, and prices reasonable.

There is something strange about a system in which people buy insurance for anticipated, universal, and certain expenses like check ups, aches and pains medicine, or vaccinations. What if your business forced you into grocery insurance, for example?

By and large, people have no incentive not to use the coverage for which they've made an expensive prepayment. So, we have large scale socialized subsidies for regular medical care people should buy themselves. And we have medical providers stuck under burdensome state and industry regulations.

[BJungNan]

Every doctor's office I have been to charge full price to the uninsured paying cash while discounting heavily for insurance companies that take forever to pay and require gobs of paperwork.

Tell me that makes sense.

[BJungNan]

I think if we eliminated Medicare for all but the destitute and got the insurers out as middlemen, we could all afford good insurance coverage.

You forgot the lawyers. We have to get them out of medicine. Until then, there will be no signicant reductions in cost.

[FreePaul]

...eager to help hard-pressed patients or calculating that it can benefit their business...

A lot of these doctors are the typical insurance rip off artists who want to as many patients who are covered by insurance as they can get. Without charging the co-pay they can get the patients to come back for every little thing. Co-pay was put there for a reason. Just another flaw in the third party pay insurance system.

[Scenic Sounds]

Thanks for some informative posts.

I was reading the other day that between Medicare, Medicaid, the VA, the DOD, public hospitals and clinics, tax deductions for health care, etc., government is now paying 60& of the health care costs in the country, with the remainder being split more or less evenly between private employers/insurance companies and individuals. Are these figures far off?

[Mad Dawgg]

"It's amazing how many people go to the doctor without their wallets."

Yeah, in our area it has been so prevelant to not pay while you are at the Doctor's office for far too many years, that the last few times I've been to the Doctor and pulled out cash to pay for my visit the ladies at the reception desk had no clue what to do with me or my money.

They actually had to go ask someone how to take a cash payment.

This is why the Health Care Industry is so fubared. No one cares about costs when you don't see a bill and it is passed to your insurance company. And, when the insurance company sees their margins declining they just raise their fees.

[neverdem]

I'm glad I posted the article, just to see you respond. I remember seeing you comment for a long time and then nothing for quite a while. Are you an orthopod or osteopath?

[FITZ]

There is something strange about a system in which people buy insurance for anticipated, universal, and certain expenses like check ups, aches and pains medicine, or vaccinations.

I wish we could choose something like catestrophic-only insurance. I guess I have something almost like that now --- I chose the highest deductible plan which has the very lowest monthly premiums. Basically I would pay for any routine health care and most minor emergency care.

[.38sw]

I get calls and letters from my own insurance company suggesting cheaper meds to substitute for what my doctor and I have decided is the best for me.

I get those, along with coupons to purchase my meds OTC. The one they want me off of is Allegra. My company has 3 copay levels - the lowest for generics, the next level for brand names on their formulary, and the highest for non-formulary drugs. Allegra is not on their forumulary, so I pay the high copay. But they still want me to use something else. My allergy specialist does NOT want me to use something else, I've asked him. This practice of sending me letters and trying to get me to use an OTC drug really ticks me off. We pay plenty for our premiums, and have for years. I see a doctor (including my allergist) about twice a year, and don't have any other health problems. So they oughtta be leaving me alone...

[FITZ]

Third party payers have made a complete mess. If a doc feels compelled to commmit charity, then the doc may be an accomplice in fraud.

I could see where there could even be some fraud if a doctor didn't sign a contract and is giving certain people better prices for the same services. It's not charity if the doctor comes out ahead financially. Some "charity" amounts to some very good tax write offs too so wouldn't be charity. Also if the doctor raises the prices on the paying patients --- it becomes them who provide the charity -- not the doctor.

[bonesmccoy]

Thank you for that! I have been told several times that my insurance will not pay for a prescription because "WE" (who the heck is WE?) feel that XYZ drug is more appropriate.

The "we" is depends on what kind of health insurance you have. If you have PPO or indemnity health insurance, the "We" is the insurance company itself. If you have HMO or POS plans, the "we" is the insurance company and the pharmacy benefits company that is contracted to "control costs".

HMO's are really a "den of thieves" that have been permitted to operate in this nation based upon Clinton Administration health reform initiatives. There are direct political linkages between the executives and owners of HMO contracting corporations and the political cash contributions to the democratic candidates across California.

__________________________________________

First of all, I didn't go to the insurance company to be diagnosed...I went to my DOCTOR; so why is the insurance company involved in deciding which drug is "appropriate"?

The insurer believes that they can dictate to the physician what to do because they control the cash flow to the doctors. Under the guise of "cost containment" the people are being denied equal access to care for completely arbitrary and, frankly, political reasons.

It is my belief that there is a social engineering process under way. It is my belief that HMOs are specifically being used to target enhanced resources to particular ethnic communities and to particular geographic areas.

In my career, the HMO atrocities have included:

1. Having a hospital case manager tell me that it is more cost effective for the hospital and more merciful to the family to let a disabled child die.

2. Watching as a neonatal specialist chooses to overdose a baby born with a fatal birth defect on pain medication in order to assist in hastening the death of the infant upon removal of mechanical ventilation.

3. Hospital executives who claim their facility is under dire financial circumstances as they pay themselves $400,000 to 500,000 per year and then tag on extra $100,000 to $250,000 for "benefits". By the way, they also had expense accounts of greater than $10,000 per year.

4. Physician medical group medical directors who have directed me to send patients to UNCERTIFIED specialists because they are cheaper.

5. Hospital network sending 15 million dollars per year to off-shore bank accounts for "insurance reasons". (I'll say! Boy, I'd love to that kind of coverage! -sarcastic LOL)

_________________________________________________________

Secondly, they think we are too stupid to realize that the reason one drug is prescribed over another has more to do with under the table kickbacks than the drug's effectiveness.

Yes! The reason these "executives" believe that they can redline or prioritize who lives and who dies is that the Clinton Administration never prosecuted these atrocities. However, the BUSH PEOPLE need to start federal review of these processes...and WE HAVEN'T SEEN HIDE NOR HAIR OF THESE DOJ PEOPLE.

Specifically, the Attorney General of the US, John Ashcroft, needs to investigate under RICO the violations of the following:

1. Violation of Federal Trade Commission guidelines by Pharmacy Benefits companies, hospitals, and physician networks, to unlawfully monopolize markets. Specifically, PBMs take kick-backs from the drug company in order to have the drug listed in the network. This adversely impacts the ability of the American people to have a competitive market. In addition, the hospitals are making payments to physicians for "physician services" in direct violation of California state Business and Professions Code.

2. Regular violations of IRS non-profit rules by management at various hospitals who claim non-profit status while engaging in acts/conduct that violate IRS Revenue Rulings.

3. Regular violation of Federal Health & Human Services regulation by management at particular hospitals who regularly engage in physician relocation agreements to modify the physician marketplace despite information that the cities are not defined as "health professional shortage areas".

4. Regular violation of Federal HHS regulations by physicians and medical groups who accept unlawful relocation agreements in areas that do not match the regulatory constraints of such agreements.

5. Regular violation of insurance contracting by insurance companies that fail to reimburse medical groups appropriately for services rendered. Despite multiple complaints by my colleagues regarding the conduct of some of these groups, the California State Department of Managed Care has utterly failed in it's duties. We question what the lawyers do to gain their compensation in the DMHC in Sacramento.

________________________________________________

Insurance companies are going to be the downfall of the wonderful health care that we have enjoyed in this country. What started out as a nice cost-sharing idea has devolved into a nightmare...due to greed and avarice.

It's worse than that.

It is my belief that elements in the HMO industry are specifically attempting to carry out a Nazi-like social engineering process. I've read a book on the social engineering that the Nazi doctors were being asked to carry out in the 28-36 time frame. The same moral stances were being advocated by the Nazi's and the HMOs. The same social engineering processes are at play.

The Nazi's and the HMO industry both regularly decline coverage for children who are of particular ethnic groups. Management in HMOs tend to reflect a VERY RESTRICTED range of ethnicities and if a racist ends up in a key management position, the racist can quietly resolve to disadvantage the people of particular ethnic groups or political pursuasion in that area of our nation. In healthcare, this disadvantage translates to slower care and a literal killing of those families/individuals so targetted.

FOR THIS REASON, the Bush Administration DOJ needs to become far more assertive with enforcement of regulations on the HMO industry.

[bonesmccoy]

See my posting above regarding violations of Federal and State of California regulations.

I am distressed that the federal administration has not quickly sought to break up the HMO industry when it is so clear that the industry is part of the bust-out strategies that were occuring during the Clinton Administration.

There are direct relationships between elected officials and the various HMO insurers.

Do you understand how capitation works?

I would like to explain the process publicly in this forum so that Free Republic readers understand why they can not get adequate access to medications and physicians when necessary.

Essentially, there is more than enough money in the federal system to resolve health access problems. The biggest problem with the physician is not standing up to fight for what we do.

I am interested in cutting out the red tape and have done so.

Any individual, including hospital executives with off shore bank accounts, who interferes with our team of physicians will be identified, targetted, and smoked out.

I'm not interested in spending time arguing with bought off politicians about these issues. I already KNOW what is happening.

The question is NOT whether or not my point of view is correct. IT IS BASED ON PERSONAL EXPERIENCE IN THE INDUSTRY.

I have assembled a team of like minded physicians and any politician that crosses me will be publicly chided during this election year.

WE LOOK FORWARD TO COOPERATION but will take action against those in authority who have FAILED US.

[Jim Noble]

and there's no mention made (or so it seems) of formulary status, cost, or co-pay for the script

Nor should there be.

I don't know, and I don't care, about "formulary status". When I prescribe, I try to choose the right drug.

After that, it's not my problem.

Stop trying to make it into my problem-I'm refusing delivery.

If you get into trouble for keeping people from getting what they need, good-it's just what you deserve.

[ArmstedFragg]

closed my office (private solo practice)

You certainly shouldn't feel alone. I'm in California, and all of the solo practitioners I know who are in generalist fields are struggling to stay afloat. It's a real tragedy for the patient because, I strongly believe, the best medicine is practiced by one physician working with one patient with whom she or he has a long acquaintance. Until I moved recently, I was a long time patient with one of the "last of the G.P's" who would regularly make diagnostic decisions based on his knowledge of how the patient normally looked or behaved.

Sadly, the squeeze has come from multiple directions. In the eighties, my physican owned and operated his own blood testing facility. He also regularly cajoled drug reps into giving him large amounts of free samples which he then doled out to his patients, and he had long-time employees who ran the financial end in a highly professional way.... you paid the co-pay, or you went home. As a result, the patients benefited by paying less for testing, nothing for the first month or more of most prescriptions, and being able to deal with people with whom they had an ongoing relationship.

That's all changed now. He struggled with it for several years, as reimbusements decreased, he was ordered to stop doing his own blood testing, etc. Essentially, the application of the law and rules left him without any of the ancillary revenue sources that used to help underwrite the cost of the practice. The final straw came when an insurance company sent him a letter demanding that he begin printing the entries in his charts because they were having difficulty reading his handwriting.

He walked, saying he'd signed on to practice medicine, not insurance. He's probably now sitting on a tropical beach somewhere, sipping punch, and signing the chit in the same "unacceptable handwriting".

The other movement that's become common out here is for generalists to become specialists. Radiation Oncology seems to be a popular choice.

[bvw]

Great article, that presents the pratical facts. Thanks and happy new year to you!

* * *

Here's a telling quote from the article:

Dr. Herbert Dardik, chief of vascular surgery at Englewood Hospital and Medical Center in New Jersey, scorns collecting co-payments. "I look at it as a demeaning process," he said. "I tell my secretary upfront, if there's any issue, just forget it."

Aye, but does the repected Doc Dardik scorn collecting payments?

[Jim Noble]

You're absolutely right, Doctor. That patient of yours should be able to fill any script you write with no issues at all. What should we set the copays at? Five dollars for a 90 day supply? What should the premiums be? Maybe thirty dollars a month?

The co-pays and premiums you charge are your business, not mine.

I don't care.

Stop bothering me about it.

[bonesmccoy]

I agree with your comments regarding the training we get as board certified physicians.

I hope we can continue this open discussion for the benefit of the citizens.

You have been caught in a gambit that has been played here in Southern California for several years.

Younger physicians are forced from the market through the HMO contracting pool. When HMO enrollment reaches a particular penetration in the market, sufficient cash flow is STOLEN from the patient-physician relationship BY the hospital/HMO collaborative.

The issue is that federal and state officials in Texas permitted HMO's to collapse the PPO market by offering pie-in-the-sky estimates.

HMO contracts are NOT based upon rational projections or accounting processes. In fact, they STEAL from the physician-patient relationship in favor of giving money to the risk pools controlled by the hospital and the Pharmacy benefits management companies. This results in a collapse of funding to private-primary-care doctors offices, like yours and mine.

Because HMOs do not reimburse according to services provided, you are left bankrupt due to your commitment to moral medicine.

I have been lectured by older physicians who control boards of directors that I need to remove my physician hat and put on my executive hat. I'll do that when hell freezes over.

[bonesmccoy]

regarding coding of a common cold... NO, you're wrong. The coding varies depending on the symptoms and signs in the patient and the definitive diagnosis.

It is NOT overinflation of cost to adequately code the encounter.

Are you a physician or registered nurse?

Are you a medical biller?

[bonesmccoy]

What should we set the copays at? Five dollars for a 90 day supply? What should the premiums be? Maybe thirty dollars a month?

Frankly, your corporations should cease to exist and that would save the insurance companies tons.

What savings does your corporation bring?

Please post your corporate financials!