Tuesday, October 8, 2013

Two [remunerative] roads diverged in a wood...

"and I -- I took the one less traveled by, And that has made all the difference."  I love Frost and this seemed an apt observation, especially given the fall weather.  One road takes patient insurance; the other does not.  In the swirling mass of ideas from which my vision for better healthcare delivery will congeal is this fundamental divergence.

I have already long ago negotiated most of my contracts with insurers, the  relationships with which only need be redirected to whatever my new endeavor becomes.  I also know and understand the remunerative process in clinic medicine better than most.  I speak CPT, ICD, HCPCS, etc. and  understand the tools to assure prompt and satisfactory payment.  But most importantly, the majority of my potential patients will have some form of health insurance, which they will want to use with me.  With the Affordable Care Act in full swing, that number will rise.

However, once inured to the payors the bureaucracy compounds.  Complex and expensive practice software need be purchased/leased, often in a commensurate hardware environment, particularly if you decide to avoid "The Cloud."  After the initial "ooooffff" of those expenses, there is the time needed to verify insurance.  Mr. Jones may think he is insured when he shows me his little wallet card, but it is not until I contact the payor that I can verify that this is the case.  If I don't do this, and he is not insured, he is really not obligated to pay for any service already rendered.  And that process must happen every time his insurance changes.  Then there is the hard job of helping him understand that he has not met his $1500.00 deductible, so his visit will all be out-of-pocket today.  And some medications, depending on lengthy and plan-specific formularies, may not be covered, or will require several pre-authorization forms to be submitted first before coverage will be considered.  There is a labyrinthine tier of rules regulating the quality and quantity of clinician documentation requisite for different levels of remuneration from the payor.  With the growing presence of integrated health quality reporting tools, even more data must be collected, mined, and processed, modest returns notwithstanding.  The EOBs, or explanation of benefits, if readable, often prompt questions from the patients.  "Why was I charged for this?" or "What does that mean?"  Overcharges and undercharges are not uncommon.  Co-pays ranging from $5 to $50 must be collected at the point of care, and should never be waived, as this is a form of insurance fraud.  And the clinician will be deluged with mail and email about this or that new program the payor has instituted to assure compliance, payment, etc.  In some cases, these letters -- often "reminders" -- appear to be offering clinical advice and suggesting courses of treatment (all too often based on insufficient evidence), in what appears to me to be a violation of the Texas Medical Practice Act.

All of this makes the Sirens' song of direct fee-for-service much more attractive.  "Mr. Smith, I'll take care of your sinus infection for $50."  Done, simply and cleanly.  No loose ends or hanging chads.  Sure, one needs some form of accounting software, but it has to be more simple that the above.  The majority of the bureaucracy above disappears in this model.  I am working on a different name than "cash-only."  Perhaps "chickens optional?"  Whatever the name, it must be positive, as I shape the brand essence of this nouveau passe approach to meeting people's needs.

The downsides to divorcing my payors are protean, but none are dealbreakers.  Long-term and repetitive care issues (e.g. wound care) pose potential challenges, but there must be a way to structure this simply and make it achievable for every person.  What if complex testing must be considered (e.g CT scan, MRI)?  As an experienced clinician, retrospective evaluation of many outpatient clinical scenarios suggests that higher level testing does not change outcomes in the majority of cases, particularly in the arena of repeated/serial exams, and direct contact with the clinician.  Blood tests could be drawn and submitted to a national reference laboratory cost effectively.  And medications?  One proposal to make this model of simple care more attractive is to offer a simple and common array of medications to the patient at the point of care, obviating the headache of a pharmacy visit.

Perhaps it has all been done before, however.  Some urgent care facilities only take cash/credit, and have a structured tier to payment that emulates my thoughts above.  Often these facilities have not addressed well-enough the hurdles of triage/wait times, availability, and over-testing.  In this, and other ways, I hope to be different.

While I generally disdain those whose bearishness prompts routine counter-culture arguments, I do believe that the Emperor of American Healthcare is quite naked, and I believe that my countrymen are starting to realize this too.  (The Emperor, however, seems to think he looks pretty good.)  Ultimately you must decide.  Most are tired of long office waits, of not being able to speak promptly to trusted authorities about their health concerns when they arise (invariably on Saturday night), of being inundated regularly with a flood of  paperwork (enrollment, EOBs, medication flyers, etc.), and ultimately of only getting a brief moment of face-time with the one person whose experience and background may provide answers and/or reassurance.  There is no sense of value here.  Only a hopeless sense of loss of control.  Life isn't this hard.

Much more to write and share.  Thanks for reading.  Give me your thoughts if you have a moment.  I welcome them!

Dr. P

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