Now that Open Enrollment in Individual Health Plans is over (for most folks,) what do you do now?
For starters, go to either the webpage or the healthplan's book and check out what it is you actually purchased. You need to know three numbers - your premium, of course, your co-pay, and your deductible. When you selected your plan, you should have noted each of these numbers but many haven't. Please note them now for the true cost of your plan is not merely the monthly premium.
Now look at the "Provider Book" or the list of so-called Healthcare Providers on the plan website. Being a physician, let me point out that I didn't go to "Provider School." But that's a matter for another day. If you have an ongoing relationship with a doctor, make sure that your doctor is on the network list. If you can't find this information, call the plan's info number and find out. Again, you should have checked this out before choosing a plan, but that's water under the bridge now. Most if not all of the new individual plans set up under the "Affordable Care Act" are In-Network only plans and these networks are usually quite narrow with fewer choices. If after calling the plan and/or your doctor's office, emailing the plan, or sending out an APB, you still can't find out if your doctor participates in this plan, alert your state's insurance department. In NY State, that would be under the Department of Financial Services. Unfortunately for many, you may have to choose a new Primary Care Physician and you should do so asap. If you have a chronic illness for which you are undergoing treatment, you also have to find out if your specialist doctors are "in network" as well. If not, sadly, you will have to choose whether to pay a rather large bill for care or switch to a whole new set of treating physicians and start from square one.
Here's the problem - these new plans are for the most part "In Network" only. That means that whatever benefits your plan involve services provided only by In Network Providers. There are NO Out of Network Benefits for most Individual Plans save for a few scattered exceptions. If you need to go "Out of Network," the insurance version of "Off the Res," NONE of those services will be covered unless you get a special dispensation from the plan's hierarchy, usually the Medical Director. For example, if you have advanced colon cancer and wish to be treated at a Cancer Center like NY's Sloan Kettering which you find is not in your network, expect that you will be responsible for the entire bill. Moreover, and here's the kicker, none of the money you shell out will count toward your plan deductible - zip, zero, nada.
If you do not think this is fair, you are not alone. Unfortunately, the law isn't about fairness and it is what it is. My suggestion is that while you're still upset, you contact the State Insurance Dept (Again, in NY State, the Dept of Financial Services) and register a complaint. You should also call your state legislator and your local news consumer affairs reporter. The more light you shine on this issue, the sooner this will be dealt with. Everyone in NY State I've spoken with has acknowledged this problem with the individual plans.
Now, you may luck out. You may be healthy, not need care, and, if you do, find In Network doctors who are competent, caring and professional to handle your medical issues. But it shouldn't be left to luck, chance or God, should it?
Realize also that many doctors are in the same boat. It seems the plans were not so forthcoming at giving doctors the choice of either joining an insurer's new plan networks or informing them that they were either in or out of the new narrow network. This is a recipe for chaos. Also, if the plan lists a doctor as In Network but the doctor really is not, you will assuredly get a bill. And as I pointed out above, that bill will not count toward your deductible.
In reality, most of these plans are the worst of all worlds - an amalgam of an old HMO with a High Deductible Plan. There's little anyone can do about this situation right now, unfortunately. If you do run into a problem, please don't take it out on the doctor. Most of the doctors I know have been pleading with the states to do something as the end of enrollment approached. During the Second World War, the motto in Britain was "Keep Calm And Carry On." Both doctors and patients will need to do that. However, that doesn't mean you shouldn't complain. You should. For sure, it really is the squeaky wheel that gets the grease.
One last suggestion - other resources you should consider are your County and State Medical Societies. They have dedicate staff who are well-acquainted with the situation and are well-positioned to get you advice and also, to pursue your issues as they meld with their doctors' issues.
"Fasten your seatbelts, it's going to be a bumpy night." Bette Davis
Showing posts with label Healthcare Reform. Show all posts
Showing posts with label Healthcare Reform. Show all posts
Tuesday, April 1, 2014
Sunday, March 9, 2014
Quo Vadis
NJ Medical Society Past President Ralph Kristeller MD gives Fee For Service some historical perspective.
Fee For Service does not operate in a vacuum. It operates in an environment.
My apology in advance for this long email; however, the subject “Fee For Service” urgently requires an airing.
In January 1963, after 8 years of active duty in the US Air Force – the largest HMO in the world at the time, I completed my obligation under the “doctor draft” law. I returned home to Millburn NJ where I rented space in a building almost fully occupied by physicians in solo or 2 or 3 partner practices and opened my office for the solo practice of Internal Medicine. Having entered Military Service the day I graduated from Medical School, I had no experience as a physician in civilian life. An older seasoned Internist gratuitously told me “Ralph it will take you a year to establish your “fee schedule.” How correct he was. Nevertheless I began by charging $5.00 for an office visit, $10.00 for a house call $15.00 for an EKG and $20.00 for a PA and Lateral Chest X-ray.
My cost for doing business included my rent, salary for a part time secretary, interest on my loan, premium payments for disability insurance and premiums for a medical negligence policy. The premium for the negligence policy was less than $100.00 a year.
I applied for membership in my County Medical Society. In order to qualify for full membership I was required to accept call by roster for 2 years. This entailed taking call for the Society’s answering service.
Patients who had an “emergency” and did not have a physician called the County Medical Society and I was required to respond with a house call. There were, as yet, no Emergency Rooms. Other than Blue Cross/Blue Shield, a.k.a the Surgeons Plan because it only covered hospitalization, there were no third party payers. It was a cash and carry system IF the patient had the cash. Otherwise it was Pro Bono.
In addition I applied for membership on the Staffs of two local hospitals. Again there was a requirement for participating in the hospital’s “clinic” which met, as I recall, every 2 weeks. This of course was also Pro Bono.
Since “time is money” Pro Bono must be considered a cost of doing business and therefore factored into my fee schedule. Accordingly, my challenge was: If I set my fees too low I would be in financial difficulty, if I set my fees too high, I lost the patient, the patient’s family and any potential patient referrals. Furthermore, if I failed, in the patient’s opinion, to provide value for my fee, the patient walked across the hall and made an appointment with an older more established physician. Parenthetically, I garnered some patients who walked across the hall to me from my competitor because of patient dissatisfaction. In my view this real world experience is “fee for service” in its pure form.
In 1966 Title XVIII, Medicare, became the law of the land. It promised non interference by government in the practice of medicine and non interference in the fees charged by physicians.
Well, everyone knows what happened and is happening to that promise.
Most importantly failure to keep a promise to the public by government was a little noted C change in the culture of our country and our country continues to pay a very dear price for that change.
To continue - In the 1970’s the Plaintiffs Bar found the deep pockets in negligence litigation.
The cost of doing business for physicians escalated tremendously due to the steep rise in the cost of negligence policy premiums. Paradoxically physicians were conveniently blamed for charging too much for their services. In addition physicians were accused of ordering unnecessary tests in order to increase their incomes. However, what was never brought forth was the astute observation by Mr. Chuck Hardwick when he ran unsuccessfully for Governor of NJ. He stated: “The power to sue is the power to terrorize.” Extra testing as a defense against terror by rational physicians was mischaracterized as “unnecessary testing” by politicians for their own self interest. It has been estimated that the added cost to our current health care system, due to “mal practice” expenses, is 50 Billion dollars a year. For politicians the medical tort system is the third rail and they refuse to touch the issue. However, unassailable studies by Professor Localio et al have shown that our medical tort system does almost nothing to compensate truly injured patients. Meanwhile for the country it creates an economic disaster.
By manipulating the words, and thereby poisoning minds, politicians captured public attention and focused the debate on the need to control cost, implying that physician fees are the main culprit.
However, the facts are that Physicians have been under price control ever since the promise of non interference by Medicare was broken. More importantly there has been no attempt to control practice costs which are the main ingredient in physician fees. Rather it has been politically profitable to blame physicians rather than deal with the core issues that contribute to the real cost of our healthcare system.
In short the “Victims (physicians) Are Blamed For the Crime.”, quality of medical care, as defined in AMA policy, continues to deteriorate, the lobbyists and the politicians continue their lucrative careers and the country is, according to the polls, going in the wrong direction.
Finally: Two thoughts come to mind:
"No one can make you feel inferior without your consent." Eleanor Roosevelt
More to the point:
Ann Landers adage: "If you act like a doormat, don’t be surprised when people wipe their feet on you."
Respectfully
Ralph Kristeller
Well said, Dr. Kristeller.
Fee For Service does not operate in a vacuum. It operates in an environment.
My apology in advance for this long email; however, the subject “Fee For Service” urgently requires an airing.
In January 1963, after 8 years of active duty in the US Air Force – the largest HMO in the world at the time, I completed my obligation under the “doctor draft” law. I returned home to Millburn NJ where I rented space in a building almost fully occupied by physicians in solo or 2 or 3 partner practices and opened my office for the solo practice of Internal Medicine. Having entered Military Service the day I graduated from Medical School, I had no experience as a physician in civilian life. An older seasoned Internist gratuitously told me “Ralph it will take you a year to establish your “fee schedule.” How correct he was. Nevertheless I began by charging $5.00 for an office visit, $10.00 for a house call $15.00 for an EKG and $20.00 for a PA and Lateral Chest X-ray.
My cost for doing business included my rent, salary for a part time secretary, interest on my loan, premium payments for disability insurance and premiums for a medical negligence policy. The premium for the negligence policy was less than $100.00 a year.
I applied for membership in my County Medical Society. In order to qualify for full membership I was required to accept call by roster for 2 years. This entailed taking call for the Society’s answering service.
Patients who had an “emergency” and did not have a physician called the County Medical Society and I was required to respond with a house call. There were, as yet, no Emergency Rooms. Other than Blue Cross/Blue Shield, a.k.a the Surgeons Plan because it only covered hospitalization, there were no third party payers. It was a cash and carry system IF the patient had the cash. Otherwise it was Pro Bono.
In addition I applied for membership on the Staffs of two local hospitals. Again there was a requirement for participating in the hospital’s “clinic” which met, as I recall, every 2 weeks. This of course was also Pro Bono.
Since “time is money” Pro Bono must be considered a cost of doing business and therefore factored into my fee schedule. Accordingly, my challenge was: If I set my fees too low I would be in financial difficulty, if I set my fees too high, I lost the patient, the patient’s family and any potential patient referrals. Furthermore, if I failed, in the patient’s opinion, to provide value for my fee, the patient walked across the hall and made an appointment with an older more established physician. Parenthetically, I garnered some patients who walked across the hall to me from my competitor because of patient dissatisfaction. In my view this real world experience is “fee for service” in its pure form.
In 1966 Title XVIII, Medicare, became the law of the land. It promised non interference by government in the practice of medicine and non interference in the fees charged by physicians.
Well, everyone knows what happened and is happening to that promise.
Most importantly failure to keep a promise to the public by government was a little noted C change in the culture of our country and our country continues to pay a very dear price for that change.
To continue - In the 1970’s the Plaintiffs Bar found the deep pockets in negligence litigation.
The cost of doing business for physicians escalated tremendously due to the steep rise in the cost of negligence policy premiums. Paradoxically physicians were conveniently blamed for charging too much for their services. In addition physicians were accused of ordering unnecessary tests in order to increase their incomes. However, what was never brought forth was the astute observation by Mr. Chuck Hardwick when he ran unsuccessfully for Governor of NJ. He stated: “The power to sue is the power to terrorize.” Extra testing as a defense against terror by rational physicians was mischaracterized as “unnecessary testing” by politicians for their own self interest. It has been estimated that the added cost to our current health care system, due to “mal practice” expenses, is 50 Billion dollars a year. For politicians the medical tort system is the third rail and they refuse to touch the issue. However, unassailable studies by Professor Localio et al have shown that our medical tort system does almost nothing to compensate truly injured patients. Meanwhile for the country it creates an economic disaster.
By manipulating the words, and thereby poisoning minds, politicians captured public attention and focused the debate on the need to control cost, implying that physician fees are the main culprit.
However, the facts are that Physicians have been under price control ever since the promise of non interference by Medicare was broken. More importantly there has been no attempt to control practice costs which are the main ingredient in physician fees. Rather it has been politically profitable to blame physicians rather than deal with the core issues that contribute to the real cost of our healthcare system.
In short the “Victims (physicians) Are Blamed For the Crime.”, quality of medical care, as defined in AMA policy, continues to deteriorate, the lobbyists and the politicians continue their lucrative careers and the country is, according to the polls, going in the wrong direction.
Finally: Two thoughts come to mind:
"No one can make you feel inferior without your consent." Eleanor Roosevelt
More to the point:
Ann Landers adage: "If you act like a doormat, don’t be surprised when people wipe their feet on you."
Respectfully
Ralph Kristeller
Well said, Dr. Kristeller.
Monday, December 30, 2013
Calling A Code on Codes
As the Ball drops in Times Square, a new coding system will be rapidly approaching. 2014 will be the year of ICD-10.
The changes are unrelated to the Obama administration’s new health care law. But given the lurching start of the federal health insurance website, HealthCare.gov, some doctors and health care information technology specialists fear major disruptions to health care delivery if the new coding system — also heavily computer-reliant — isn’t put in place properly.
They are pushing for a delay of the scheduled start date of Oct. 1 — or at least more testing beforehand. “If you don’t code properly, you don’t get paid,” said Dr. W. Jeff Terry, a urologist in Mobile, Ala., who is one of those who thinks staffs and computer systems, particularly in small medical practices, will not be ready in time. “It’s going to put a lot of doctors out of business.”
Doctors already spend more time with the computerized EMR than with face to face patient encounters as it is. Switching to an entirely new coding system on top of an already cumbersome EMR is not going to enhance the doctor-patient relationship. What's suitable for large scale health systems and Accountable Care Organizations is not necessarily a good fit for a 3 doctor group in Jamaica, Queens. Top down mandates seem the antithesis of patient centered care. Don't expect great Press-Ganey's, folks.
Of course that's just my opinion. I could be wrong.
Friday, December 20, 2013
Holiday Wishes
Christmas/Holiday Greetings to All Elected Officials - State and National
December 20, 2013
Dear Friends
Thus far, healthcare reform has been a debacle. From website
crashes, security breaches, and mass cancellations of insurance plans, the new
law has turned hope into anger and despair. Healthcare was supposed to be
patient centered, with the doctor patient relationship at the center of everything.
Now, patients assured of keeping their doctors are losing them. Patients
assured of keeping their healthplans are losing them. In fact more are losing
coverage than gaining coverage. No one is happy about any of this. I suspect
that deep down, whether D or R, Left or Right, you too are unhappy as well.
Fear not, real help is on the
way. A group of motivated physicians are working together to assemble a
blueprint for the way forward – a reform of the reform if you will. This time,
it is the real healthcare experts, the patients’ physicians who will lead the
reform. All we ask for at this time is for your time, your attention and your
support. I promise you it will be worth it.
Doctors are not looking for
credit. What we are looking for is the solution. During this season of hope and
renewal, be of good cheer. We will find the solution. Our patients are counting
on it.
Thank you for your attention.
Sincerely
Art
Monday, November 25, 2013
Lemon of a Law
If PPACA, aka The Unaffordable Insurance Act, were a car, folks could recoup under the lemon law. We now know that if you like your plan, despite the president's "fix," you probably can't keep it. Some states like NY have already said it's too late to roll back that clock. Other states might be willing to go along but it depends on state regulators.
We also learn that if you like your doctor, you may not be able to keep your doctor. You may not be able to use your local hospital either, for that matter. Insurers have been both cutting their networks and decreasing their share of the payments to the doctors and hospitals for their services. Some prestigious NYC hospitals, like Langone Medical Center, have declined to participate in many of the new plans. Many doctors are also declining to participate or find (att some difficulty, I might add) that they've simply been dropped from the networks.
Without going into the Epic FAIL that is Healthcare.gov, many who are able to get to shop for insurance are experiencing firsthand the meaning of sticker shock. I guess that promise that folks would save about $2500 on their insurance costs was an "incorrect promise" also.
I ask you, when did we elect Joe Isuzu?
We also learn that if you like your doctor, you may not be able to keep your doctor. You may not be able to use your local hospital either, for that matter. Insurers have been both cutting their networks and decreasing their share of the payments to the doctors and hospitals for their services. Some prestigious NYC hospitals, like Langone Medical Center, have declined to participate in many of the new plans. Many doctors are also declining to participate or find (att some difficulty, I might add) that they've simply been dropped from the networks.
Without going into the Epic FAIL that is Healthcare.gov, many who are able to get to shop for insurance are experiencing firsthand the meaning of sticker shock. I guess that promise that folks would save about $2500 on their insurance costs was an "incorrect promise" also.
I ask you, when did we elect Joe Isuzu?
Wednesday, September 4, 2013
Texas Tort Reform - Ten Years Later
From the Texas Medical Association:
... Ten years ago, TMA physicians and medical students banded together to push for passage of landmark medical liability reforms. The Medical Malpractice and Tort Reform Act of 2003, House Bill 4, went into effect Sept. 1 that year. Twelve days later, Texas voters approved Proposition 12, an amendment to the Texas Constitution that validated the legislature’s actions. HB 4 caps noneconomic damages in medical liability cases. Texas’ $750,000 total cap includes a $250,000 liability limit per physician for noneconomic damages such as pain and suffering. The tort reform act doesn’t restrict economic damages.
... Ten years ago, TMA physicians and medical students banded together to push for passage of landmark medical liability reforms. The Medical Malpractice and Tort Reform Act of 2003, House Bill 4, went into effect Sept. 1 that year. Twelve days later, Texas voters approved Proposition 12, an amendment to the Texas Constitution that validated the legislature’s actions. HB 4 caps noneconomic damages in medical liability cases. Texas’ $750,000 total cap includes a $250,000 liability limit per physician for noneconomic damages such as pain and suffering. The tort reform act doesn’t restrict economic damages.
Since that law passed, record numbers of physicians have relocated here to care for Texas patients. Physicians already practicing here say they can recruit more specialists trained in Texas and from out of state, thanks to tort reform. In the fiscal year that ended Aug. 31, 2012, the Texas Medical Board received 4,253 medical license applications and processed 3,630. Compare that to 2003, when the board received only 2,561 applications and processed 2,513.
“Tort reform has done wonders for the state by attracting more physicians to practice here, improving access to care, and making it economically possible for physicians to continue caring for patients,” Dr. Justin Hensley said.
Read the whole thing.
Liability Reform IS Healthcare Reform.
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