Lack of Customer Service in the USA

[MikePA]

We need the government to regulate health care insurance like they do with car, life, and house insurance but not MANAGE the insurance. And let ME pick my policy not my employer. Give me the tax break not my company. Then *** I *** can decide which company provides the best price and SERVICE. Right now I don't have a choice. I have to use my company's health care. The insurance companies have no real incentive to provide good SERVICE. They have to hold down costs so they will be picked as a provider again. Service is way down on the priority list.

Anyone who thinks the govt doesn't regulate insurance companies isn't paying attention. Where do you think mandatory coverage for certain ailments come from? Governments do this all the time because lobbyists from providers who will make money off it get their way. When coverage is mandated, everyone pays for it. The latest is mandatory coverage for autism up to the age of 18.

The problem is you couldn't, as an individual, go on the open market and buy health insurance for the same amount you're paying through payroll deduction. If you're not getting good service, complain to your company. They should have quality and performance criteria in their agreement with the insurance company. Your company should also offer a high deducible plan where you pay the first $3,000 of expenses. Most companies offer this at no charge to the employee.

 

[riptides]

I think the gravity of the situation can be summed up in a simple fact:

The barrels (tubes) for the most advanced tank in the world, our Abrams tank, are made in Germany.

Now, I'm not saying the Germans don't make good artillery, in fact, history would suggest that they make the very best. But when you can't make the weapons that defend you then you are dependant on someone else, who may not have your best interest at heart, for your own freedom. That's a problem folks, and while this example might be trivial in its practical implications, it is not trivial in the picture it paints.

This is not a problem. This is a solution to many problems introduced with geographical deployment of the war fighting unit, the supplies for the munitions, the standardization of munitions and the leathality of the muntions and barrel (tubes) combination itself.

If we so choose to do so, the barrel can be swapped out. Going back to a USA produced and rifeld (tube).

Rest easy.

 

[WVBill]

N80

When I contract a rate with an HMO or insurer it is considered a 'discount' rate. If I charge that rate to uninsured patients then the HMO is not really securing a discount for its members. Thus, it is against the law for me to charge the same rate.

So doc, I've always wondered about the "business" side of your profession and since you opened up this area, I'll ask.

As background, my wife and I have owned small retail businesses and I know that when we offered a discount we cut our profit margin on that item - but offering a discount was either 1) an "advertising" strategy to get people in the door expecting that in addition to the discounted product they would buy others at full margin or 2) an effort to move aging product. And, yes we could not advertise something as "discounted" unless it actually was discounted. Although I'm not really sure what "law" stated that.

Obviously, niether of the traditional business reasons we had for retail discounting applies to your business.

So here are my questions:
Do your discounted contract rates cut your profit margin for those services below your business planned profit margin or do you make full margin on the contract rates and get extra margin from the non-discounted rates paid by the uninsured? Or, do you make your business planned margin on the blend of discounted and non-discounted rates?
What percentage of you business is discounted contract rate v.s. full uninsured rate?
Is it actually against a "law" for you to charge everyone the contract rate or is it against the provisions of your contract with the HMO/Insurers?
I'm pretty sure in the retail business, the "law" says that a manufacturer can "suggest" a retail price but the retailer can charge what he/she wants.

As a small business person, my head just spins trying to figure out how you deal with the business side....

Thanks for sharing

WVBill

 

[N80]

This is not a problem. This is a solution to many problems introduced with geographical deployment of the war fighting unit, the supplies for the munitions, the standardization of munitions and the leathality of the muntions and barrel (tubes) combination itself.

If we so choose to do so, the barrel can be swapped out. Going back to a USA produced and rifeld (tube).

Rest easy.

I don't think that is a reassuring as you must think it is. If you need a good smooth tube and it is so special that only another country can make it then you are dependant on someone who could be your enemy in short order.

I will rest easy....but there are other reasons for that.

 

[N80]

Obviously, niether of the traditional business reasons we had for retail discounting applies to your business.

That's the whole problem. We, the medical and insurance organizations need to operate on a traditional, competative business model.

Do your discounted contract rates cut your profit margin for those services below your business planned profit margin or do you make full margin on the contract rates and get extra margin from the non-discounted rates paid by the uninsured? Or, do you make your business planned margin on the blend of discounted and non-discounted rates?

I don't know. I'm terrible at business and so I'm basically an employee of a large non-profit hospital system. So I don't know what goes into the business plan and it is extremely complicated. But I'll tell you what I know. The hospital system contracts with the insurance companies. So lets say they contract for my basic office fee to be $50. Once that is set then they will say that they will pay $40, thus the 'discount'. But, of course, it isn't a discount at all since both numbers were agreed on ahead of time. But its more complicated than that because the sometimes agree to pay only a percentage of the discounted rate. Co-pays come into play as well. And then actually getting that money from them at all is like pulling teeth and our 8 doctor practice employs FOUR full time billing staff.

Now, if I were in a small privately owned practice I would have no leverage to negotiate with these big insurers and they would low-ball me. So I'd only be able to contract for say $35 as my standard rate and that would be 'discounted' down to $25. Etc Etc. But, being part of a large organization, we get good rates with average discounts.

What percentage of you business is discounted contract rate v.s. full uninsured rate?

Mostly discounted contracts. The numbers I used above are not our true fees. They are much higher. Again, they are not what I actually get paid. Patients see a bill for an office visit and get all upset. I will see less than half of that figure. We see some uninsured, but the truth is, virtually no one can afford these artificially inflated rates. We see a percentage of Medicare but as little as possible. We make little money on Medicare and its getting even lower. It could get to the point soon where we break even or lose money on Medicare. We see a tiny amount of Medicaid. Every time I see a Medicaid patient I lose money. In other words, it costs ME to se Medicaid.

Is it actually against a "law" for you to charge everyone the contract rate or is it against the provisions of your contract with the HMO/Insurers?

Both. The contract is legally binding. I do have leeway to charge less than the contracted rate for specific patients for specific reasons. But I can't give the discounted rate or lower to everyone without insurance. I can, however, see a patient for free. The system I work for discourages it and I get paid based on what I bill (not a salary) but the truth is, I see a fair number of people for free. Shoot, lawyers are required to do a certain amount of pro bono work so it sure isn't going to hurt doctors to do it. It makes me feel good to do it and I know for a fact that the reward for doing so is greater than the expense (call it fate, karma, God or whatever you will, but giving comes back to you).

As a small business person, my head just spins trying to figure out how you deal with the business side....

Me too. I can't and couldn't do it. That's why I sacrifice some autonomy to have the system do it for me. I know very few physicians anymore in small, privately owned practices. The insurers beat them up so bad. They get paid way less for the same work than I do.

And I won't lie. This bloated, crazy, convoluted system has been profitable for many of us in large medical systems that can contract and manage all this garbage.

However, I'd trade it all in a minute to get back to a true small business model in which most people paid me for the services I rendered them. And I'm convinced the business would be just as good since I could cut overhead easily by 75%. We 8 doctors have something like 40 employees not including the management, accounting and legal services we get from the system we belong to. Its just nuts. I know everyone has their bellyaches, but you just cannot imagine the amount of paperwork I get everyday to satisfy these insurers, Medicare and formulary providers. You've seen the cartoons of a guy sitting at a desk behind a wall of paper work. That's a reality now.

So there. Now you all know the dirty little secrets. You also now know why fewer and less qualified people are going into medicine these days.

(I just reread a lot of this and it sounds like I'm whining. Its true that most of us don't like the current system, but the day to day work we do with our patients is still gratifiying and I wouldn't want to be doing anything else. I'm as successful as I want to be financially and could be more so if I desired but I prefer lifestyle to money. Why have it if you have no time to enjoy it?)

 

[jdbower]

Negotiating a discount for an insurance provider is actually a means of increasing business and customer base for a doctor. Let's say you're a doctor in the middle of nowhere but there is a widget factory nearby. The widget factory probably is the largest employer in the area, so if they offer HealthCo insurance it's in your best interest as a doctor to bend over and accept the lower negotiated rates. If you don't, you end up losing out on anyone insured by HealthCo since they'd be forced to find another doctor. Most people will only see doctors who take their insurance plan so the more plans you accept the more patients you have access to.

Here in NJ that negotiated rate means that primary care physicians are having a lot of trouble living a lifestyle that makes 8 years of school (and the resulting tuition bills) and 3+ years of slave labor residency worth it so more and more are migrating to the pharmaceutical and biotech industry. It'll be interesting to see how a shortage of doctors affects the whole insurance industry. Already there's a growing industry of "boutique" practices where no insurance is accepted, customers pay their own way. This benefits the doctors because they can decide what a fair rate is, customers benefit because they're not slaves to their insurance companies and don't need to change physicians every time their employer changes coverage options. Generally these physicians invest in their own business, providing the customer care and environment their patients want. Customer service exists, but you can't expect discounted prices without giving up something.

I like George's idea of using insurance only for medical disasters, after all my homeowners insurance doesn't cover painting my house or a clogged sink nor does my comprehensive car insurance pay for oil changes.

 

[Phils]

However, I'd trade it all in a minute to get back to a true small business model in which most people paid me for the services I rendered them.

And, George, I wish I could have you for MY doctor. At least we could talk tractors and that would take my BP down a few points right there!

As far as the 'discounting', what everyone must realize is that giving a discount to one but not another can leave you vulnerable to a discrimination lawsuit.

Phil

 

[WVBill]

Thanks for your candid and forthright descriptions, George.

I don't envy you - except that I'm sure you make more satisfying and meaningful impacts on people's lives as a doctor than I do in my "day job" as a Computer Systems Project Manager......

By the way - a short anecdote about dealing with the insurance bureaucracy:[FONT=&quot][/FONT]
I called my Doctor last week to make an appointment for my annual physical and the receptionist said: "The Doctor is available but I'm sorry, we can't schedule you until after May 30th - that was the date of your physical last year and your insurance won't cover more than one "Physical" each year so you'll have to wait." It wasn't a problem but talk about pinching pennies! If I scheduled my physical a week "early" every year it would be 52 years before I got an "extra" physical. I guarantee you I'm not going to be around for another 52 years. 25 or 30 hopefully but not 50.....

Thanks again, George

WVBill

 

[MikePA]

And then actually getting that money from them at all is like pulling teeth and our 8 doctor practice employs FOUR full time billing staff.

Then you deal with some lousy insurance companies or someone in the organization you work for doesn't know how to negotiate a contract. Reimbursement rates and payment times are all negotiable. We reimburse providers and facilities weekly and are moving to real time claim adjudication so the patient and the provider/facility know immediately what the reimbursement will be and what the patient will owe. The payment will then happen overnight via EFT. Regarding paperwork, you can thank the government regulations, the same government some people think are not involved in regulating health care.

The regulations around Medicare and Medicaid are equally strict. CMS sets those reimbursement rates and most insurance companies who process Medicare claims are lucky to break even on the contract. There are also customer service metrics they have to meet or they will lose more money.

In the early part of this century, medicine was focused on keeping people from dieing from diseases like TB, influenza, etc. Our medical industry has done such a good job at this, people are living long enough to get chronic diseases like COPD, diabetes, cancer, etc. Guess what, it costs a lot of money to treat chronic diseases. Guess who pays for that?

 

[MikePA]

By the way - a short anecdote about dealing with the insurance bureaucracy:[FONT=&quot][/FONT]
I called my Doctor last week to make an appointment for my annual physical and the receptionist said: "The Doctor is available but I'm sorry, we can't schedule you until after May 30th - that was the date of your physical last year and your insurance won't cover more than one "Physical" each year so you'll have to wait." It wasn't a problem but talk about pinching pennies! If I scheduled my physical a week "early" every year it would be 52 years before I got an "extra" physical. I guarantee you I'm not going to be around for another 52 years. 25 or 30 hopefully but not 50.....

If it was just one person, it wouldn't be a big deal, but multiply it by tens of thousands of people. People complain about the cost of health care, but when asked to schedule an appointment 7 days further out, more complaints. I suppose the employer could have allowed one physical every 358 days, 359 in leap years. Then people would try and schedule an appointment after only 351 days, more complaints follow.