Posted tagged ‘health care’

Convenience and quality of pediatric care at retail-based clinics versus traditional practices: Where will you choose to take your kids?

February 5, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Clinics in drug stores and big-box retailers are here to stay. Often staffed by nurse-practitioners working alone, they’re much cheaper to set up and run than a traditional practice. They need only a little corner of real-estate in the back of the store, and rely on centralized billing to further reduce costs. These clinics can provide “one-stop shopping” for customers who’d like to get their prescriptions and fill them at the same place. So it’s a win-win for the retailer. They’re cheap, they generate income, and—bonus!—they drive store traffic and support the sale of prescription and non-prescription medications from a counter only a few feet away.

But are these places a win for kids and families?

A recent JAMA Pediatrics study interviewed about 1500 parents who brought children to retail-based clinics in the St. Louis area. The parents were recruited from the waiting rooms of their pediatricians. Among the findings:

Reasons for going to the retail clinic included: more convenient hours (37%), no office appointment was available (25%), didn’t want to bother the pediatrician (15%), or because parents thought the problem wasn’t serious enough to warrant a doctor visit (13%). About 50% of these pediatric visits occurred when their own pediatrician’s office was open.

About half of visits entailed a 30-60 minute wait; about 10% waited more than an hour. (BTW: Data from Kids Health First, an Atlanta-area consortium of dozens of pediatric practices, showed that overall our practices have similar wait times.)

There was striking evidence for over-prescribing of antibiotics at the retail-based clinics. 68% of colds and flu were prescribed antibiotics, as were 29% of sore throats with a negative strep test. These antibiotics were not needed. To be fair, these surveys relied only on parental recall. We also don’t know the antibiotic prescribing practices of local pediatricians. Other studies of quality of care at retail chains have not shown a big difference in antibiotic prescribing rates. Still, the numbers from this study are way out of line with national statistics and good medical practice.

Can traditional pediatric practices like mine compete on location and convenience? We  can’t open up satellites in every neighborhood. We’ve got after-hours clinics, but not as many as the retail clinics. But perhaps we can demonstrate that we’re worth a few minutes extra time to make the appointment and drive over:

  • Care at our office is by genuine, board-certified pediatricians. Yes, many simple things can probably be addressed by adult-trained advanced-practice nurses at a drug store. But how often does something that seems simple turn out to be something else?
  • We’re here for emergency phone follow-up, and we’ll be here to reexamine and help when your child isn’t recovering as expected.
  • Our office is happy to handle many medical issues over the phone—we don’t charge for this service, it’s just part of what we do for our patients. (Obviously we cannot keep doing that if our patients use us for free phone service but actually pay someone else for care.)
  • We’ve got all of your records, and we’re here to coordinate care with specialists. Labs, x-rays, consultations—you need it, we can arrange it.
  • We’re here to get to know you and your family. Your children will get to know us, and get to feel safe knowing that their own doctor is there to help.

Are these services from traditional pediatric practices worth the trade-off in “convenience” at the local retail clinic? Wal-mart and other huge chains have decimated many small businesses. Time will tell if private practices can continue to succeed.

Advertisements

Child dying? Call your insurance company, first!

January 5, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

The action steps, in any health emergency, are: ABC. Airway, Breathing, Circulation. The airway has to be open, the patient has to be making an effort to breathe, and the heart has to pump blood. In any emergency, health care people are trained to address these, one by one, in order. Fix what you can before moving on, and concentrate on what’s going to kill the child first. Then, arrange transport for definitive care. That’s the core of life support, and how health care people are trained to respond to an emergency.

But in today’s enlightened times, health care isn’t run by people trained in health care. It’s run by bean-counting administrative flunkies who care only about saving costs.

Here’s this week’s true story: A child presented to my office in severe respiratory distress. He was not breathing well. In fact, he was barely breathing at all. We gave oxygen and supportive care, but he still needed more help—so we called an ambulance to transport him to the hospital. There, he was admitted to the ICU and received expert, life-saving care. He’s now doing fine.

Except his family now has to deal with a second nightmare. To get an ambulance to transport him, we called 911, and the county 911 service did what 911 services are supposed to do–they sent an ambulance over right away, with oxygen and trained people to get him quickly where he needed to be. But that specific ambulance company was “out-of-network”—that’s not the ambulance company that the family’s health insurance company wanted him to use. So the ambulance trip goes to “out-of-network” benefits, at a lower coverage rate with a separate deductible. And the family owes $1900 they can’t afford.

Bean-counting administrative flunky: Hello, sorry for the 30 minute wait, can I help you?

Mom: My child is blue and dying. Which ambulance company should I call for in-network benefits? Money is tight.

Bean-counting administrative flunky: Please enter your 15 digit member ID number, or say the numbers out loud.

(Etc, etc. After another 45 minutes Mom gets a straight answer to call Bob’s Ambulance Company. Bob and ambulance arrive 30 minutes later. The child is dead.)

Seriously: even if mom knew the name of the ambulance company that was “in-network”, she doesn’t get to choose what ambulance comes when she calls 911. They send whoever’s closest, whoever can help—that’s what a health provider is supposed to do. Help the patient. Unlike, obviously, the insurance company.

Bean-counting administrative flunky: Hello, sorry for the 30 minute wait, can I help you?

Mom: My child is dead. Which mortuary should I call for in-network benefits?

Bean-counting administrative flunky: Please enter your 15 digit member ID number, or say the numbers out loud.

The Affordable Care Act has helped many more people get health insurance. But the insurers are still in the business of making money, not in the business of providing health care or paying for health care. They don’t make their money by paying bills. They make their money by doing whatever they can not to pay the bills. If you want to get them to actually pay for your health care, you’ve got to know the ins and outs of the contract, and you’ve got to steer services to “in-network” providers– that includes hospitals, docs, pharmacies, and even ambulance companies.

Child dying? Forget the ABCs of airway, breathing, and circulation—your first call, now, is to your insurance company*. Do a crossword while waiting on hold. And maybe give your child a little oxygen, while he waits—just don’t expect the insurance company to pay for it.

*Though this post was 100% true, the advice in the last paragraph was “snark”, for comedic effect and narrative impact. If your child is very sick and you need an ambulance, call 911 right away. Do not call your insurance company. Later, you may have to straighten out some bills—but take care of your child, first, always.

Insurance provider lists are full of lies

December 18, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

A goal that’s become The Major Talking Point about health care reform is to get more people into health insurance plans. There are XX million uninsured, they say, and this new scheme will help provide insurance to XX people. But just having insurance won’t make anyone healthier. Insurance has to allow access to health care providers in a timely manner.

Unfortunately, that isn’t always the case. A study just published in JAMA Dermatology demonstrated that many provider lists for health care plans are outrageously inaccurate, and greatly overstate the number of providers in health networks.

Researchers in California collected the currently-published physician directories for all of the Medicare Advantage plans available in their state. They looked at one specialty, dermatology, finding a total of 4754 total physician listings. About half of these were duplicate entries, with the same physician appearing multiple times in the same directory. They called every single one of the 2591 actual unique providers, and found that only half of those could be reached, were accepting patients in the plan, and could offer an appointment. For one of California’s Medicare Advantage plans, not a single dermatologist was available. Net for all plans, about 25% of the “listed dermatologists” in the plans could actually see you as a patient – and even then, the average wait time was 45 days.

Having health insurance is important, but it’s not the same as having health. Patients need to be able to see doctors; they also need to be able to get prescription drugs or ride an ambulance if necessary. And they need the cash to meet ever-growing deductibles. Cheap health insurance isn’t really very useful if you can’t use it. While this study doesn’t speculate on why the insurance booklets are so inaccurate, it’s obvious that if the insurance companies wanted accurate provider directories, they could make them. After all, in one quick phone call I can find out if a patient’s insurance covers a visit with me. Their computers know. But if you’re a health insurer, it’s better for you to misrepresent and obfuscate and over-state your networks. Their listings say 4754 dermatologists are in-network; but less than 1500 are really available to see you.

The goal of the insurance companies (and government-funded health care coverage bureaucracies) hasn’t changed. They want to spend as little as possible on your health care. Since they can’t exclude pre-existing conditions any more, they’ve come up with new ways to keep your premiums to make big profits. Tiny, limited networks are one trick. They make it very difficult to get an appointment, and care delayed is care they may not end up paying for. Even better for them: sometimes people become so frustrated that they see an out-of-network provider, paying with their own cash. You pay—you lose; you pay—they win.

EDIT: After I wrote this, a study was published looking at Medicaid — and found that about half of the providers on the lists were retired, dead, or not seeing Medicaid patients. Half is better than 25%, but both figures are terrible. Both private and public health insurers are way overstating their provider numbers.

Thursday Roundup: Bureaucrats making medical decisions, why people cling to weird beliefs, and the next Jenny McCarthy

May 22, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Summer’s almost here, and I need to get outside to plant my ‘maters. So let’s let someone else write the blog post today! Here’s some articles written by other people that you might enjoy:

From The Wall Street Journal, “The Bureaucrat Sitting on Your Doctor’s Shoulder”. Written by Atlanta Ped Opth Zane Pollard, a chilling recap of what’s happening every day. You may think your doctor is making the decisions, but he or she isn’t the one who makes the final decision. It’s not just Medicaid, believe me. Docs spend hours every day fighting through pre-authorizations and insurance obstacles. And it’s only going to get worse.

Some psychology insight from The New Yorker: “I Don’t Want to be Right.” We know facts alone will not sway many who believe false things. Why? Our memory and our minds are not like computers—and what we believe may reflect more about who we think we are than what the world is really like.

Speaking of which: now that Jenny McCarthy is trying to re-invent herself as a somewhat-less-anti-vaccine-nutjob, who’ll be the next celebrity to pick up the fact-free fear-mantle? Apparently, none other than Alicia Silverstone. We could just ignore the inanity (parents should chew their child’s food, and kids should poop outside), but now that she’s actively trying to convince parents that vaccines and doctors are evil, she’s truly crossed to The Dark Side of Clueless.

Insurance tries to make it your doctor’s fault

January 6, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Little kids don’t like to accept blame. They’ll say “someone else did it,” or “it’s not my fault”, and they’ll look at the ground and shuffle their little feet. In their hearts, maybe they really think that someone else scribbled on the wall with lipstick.

Insurance companies know better. When they’re trying to deflect blame and obfuscate, you can bet that they know exactly what they’re doing.

Just one example: prescription drug “preauthorizations”. Even the word itself, “preauthorize” – what is that, getting permission before you get permission? Did Orwell himself make that up? I have a medical license, so, in the wisdom of the legal system, I can authorize a patient to get a prescription drug from a pharmacist. The “authorization” is the prescription, the piece of paper with cryptic scribbings and abbreviations and my unreadable signature.

Trouble is, just having an “authorization” from a medical doctor sometimes isn’t good enough. Sometimes, especially if the medication is expensive, you need a “pre-authorization,” too. And the insurance company tries to make it seem like that getting a preauth is the doctor’s job, too. If you don’t get a pre-auth, that’s the doctor’s fault. Honestly, Mom, I had nothing to do with the noodles in the clothes dryer.

No, a pre-auth has nothing to do with your doctor’s decisions. My job, my “authorization,” is based on my history and physical, the decision my patient and I made in the exam room. I already did that part, and I gave you the script. Now it’s up to your insurance company to pay for it, at whatever terms are spelled out in your insurance documents. If they don’t want to pay for it, that’s their decision. It is not mine.

Insurance companies have made up a new kind of authorization, the “pre-authorization”, that somehow has also become something your doctor is supposed to do. They’ll make it sound easy—just tell your doctor he has to fill out a form, or tell her she just has to call a “prereview specialist.” Of course, it’s never that easy. I don’t have the form, and it will take days to get it. The form itself may be complicated and many-paged, and will require me to pore over your old chart to see what other medications you’ve taken and on what dates. And a phone call? Please. We wait on hold just like you do. Me and my staff are supposed to be taking care of patients, not spending 45 minutes listening to “Muskrat Love.”

Any even when we do the form, the “pre-authorization” will often be denied. We won’t know it, but there are often “secret rules” that drug X won’t be paid for until the patient has tried drug Y and drug Z for at least 60 days. Documented, in the notes that we have to send and sign. You say those medications were tried by your last doctor, and didn’t work? That’s good enough for the doctor. It’s not good enough for the pre-authorization clerk or lackey with his red rubber stamp.

After all that, the patient gets a letter, which continues to blame the doctor: “Your request has been denied, based on the information supplied by your physician.” Needless to say, your doctor can appeal this, by spending a few more hours beating his head against a tree or contacting your insurance appeals department (those are approximately the same thing.) That won’t work either, but it will further reinforce the point of this entire adventure: it’s not your insurance company’s fault. Really. We’d love to pay for your medicine. It’s just that, between you and me, your doctor just isn’t very bright. He can’t fill out a simple form. We’d do it, sure, if only that doctor would get a preauth like he’s supposed to.

No. I’m not “supposed to.” Getting pre-auths was not part of my medical education, and it’s a huge waste of time. It’s a transparent way to make it difficult for people to get medications that they need, so the insurance company can spend less on your medical care.

That letter, the one that politely refused the preauth and blamed your doctor, it’s got one other truly Orwellian component. The letter will also tell you that the insurance company isn’t dictating treatment decisions. After all, they don’t have a medical degree. They can’t decide medical things. That’s up to the doctor. Yes sir. You can have any medicine you want. We’re just not going to pay for it. And we’ll do our best to make sure you think that’s your doctor’s fault, too. And so is the lipstick on your wall.

Patient satisfaction versus good health

August 20, 2012

The Pediatric Insider

© 2012 Roy Benaroch, MD

There’s a quiet tug-of-war going on behind the scenes in medicine. Patient satisfaction is important for business, and increasingly it’s being measured and incorporated into physician scores, salaries, and employment decisions. Doctors are being employed by clinics and groups whose administrative pygmies call the final shots—and to them, the customer is always right. Maybe this isn’t always a good thing.

What administrators look for, mostly, is happy customers and quick visits. See more patients, keep ‘em happy, and you’re a successful doctor. Patients know how to complain, and believe me: those complaints do come back to the doctor.

Take antibiotics, as an example. It’s widely known that most sore throats, coughs, fevers, and runny noses do not benefit from antibiotics. Bronchitis, upper respiratory infections, and most other ailments that make kids and adults feel bad are caused by viral infections, and will not improve any quicker with any prescription. Yet: patients and parents are more happy when antibiotics are prescribed. Not all parents, of course, but many. And it takes far more time to explain why an antibiotic isn’t needed than to write the prescription. So time pressure and administrative pressure and the pressure to make patients happy all conspire against proper medical judgment.

What’s the harm? In the case of antibiotics, you’ve got a real risk of encouraging the development of antibiotic resistance. And allergic reactions, some of which are very serious. Add to that a growing risk of complications like C diff colitis and other adverse reactions. Antibiotics are not placebos. They can genuinely harm you, your children, and your community.

A more-subtle consequence: unnecessary antibiotic prescriptions reinforce the need for more antibiotics in the future. Once the expectation is created that a cough needs a pill, it’s very difficult to break the easy cycle of cough -> doctor visit -> prescription. In the short run, this pattern helps the doctor make money and helps the patient feel like they’re being taken care of. In the long run, it costs money and does far more harm than good.

It’s not just antibiotics that are the problem. Patients sometimes seem to want extra tests and procedures that have their own risks, including radiation exposure and pain. And misleading test results, which happen so often after unnecessary tests, lead to more tests and more-invasive procedures, ratcheting up the anxiety. Again, it’s easier and quicker to just order the test rather than explain why it’s not necessary. And at least the perception is that it makes patients happier.

Are happier patients necessarily healthier patients? No. A 2012 study in The Archives of Internal Medicine, called “The cost of satisfaction”, looked at a sample of about 50,000 adults and tracked health expenses, health status, and satisfaction. The happiest patients were the ones who spent the most money on health care. And they were the most likely to die.

Patient satisfaction is important, but it ought to be fostered through good communication, honest dialog, and a partnership with a primary goal of good health. Quick prescriptions, in the long run, are costing us money and lives. We need to ask: are health care economic incentives encouraging the profitable thing, or the right thing?

To improve medical care, we need more beans to count

October 14, 2011

The Pediatric Insider

© 2011 Roy Benaroch, MD

At a time when our country is nearly bankrupt and medical costs are eating up a huge part of our taxes (and our children’s taxes, and our grandchildren’s taxes), government and insurance-industry officials have come up with a scheme that’s sure to help: more diagnosis codes!

When you visit a doctor, we come up with a bill that includes a “procedure” or “evaluation and management” code, plus a “diagnosis” code. The diagnosis code is picked from a list of about 18,000 numerical codes from a real page-turner of a book called the “ICD-9”. Those 18,000 diagnosis codes include just about anything you could think of.

But not, apparently, anything anyone could think of. Starting soon, your doctor will have to use the new, expanded ICD-10, including 140,000 codes. Included are many new codes that are sure to be useful:

W5631XD  Bitten by other marine mammals, subsequent encounter (This covers manatee attacks, but not sea lion bites. Sea lions have their own code, W5611XD)

Y92253 Injured in an opera house (note that if one were bitten by a sea lion in an opera house, the doc would be required to submit both the Y92253 and W5611XD codes.)

V9027XA Drowning and submersion due to falling or jumping from burning water-skis, initial encounter (The water skis were presumably lit on fire to scare off marauding sea lions. In the opera house.)

(Thanks to the Wall Street Journal for this clever tool to help find ICD-10 codes.)

This is not a joke. Your doctors will be required to use these new codes, which will mean getting our billing systems up-to-date to accept them. For my practice, that requires upgrading our practice management software (to do that, we must also upgrade our server, database, and OS software.) Total cost: $42,000. That could have paid for some well-deserved raises or bonuses for my staff, or even for me to hire an extra nurse. Instead, I will gain the ability to bill for “V9135XA Hit or struck by falling object due to accident to canoe or kayak, initial encounter”.

So: I’ll spend practice money in a way that doesn’t benefit my patients one bit, but rather gives the administrative pygmies more beans to count. This will (predictably) lead to a need for more support staff, more consultants, and even more administrative pygmies to implement this huge new complication. I wonder if there’s an ICD-10 code for “Health care system, destroyed by its own administrative weight and senseless overhead”?