WE'RE ALL IN THIS TOGETHER Please feel free to print and circulate any of the information
you find on this website. Please reference: http://home.earthlink.net/~austintxmd WHAT CAN A PATIENT DO? IF YOU ARE CONSIDERING A CHANGE OF INSURANCE PLANS... FRAUDULENT SALES PITCHES INSIST THAT YOUR EMPLOYER OFFER YOU THE OPTION TO CHOOSE Even if your employer leaves you stuck with one of the bad plans
for the time being, as long as you have out-of-network benefits you'll still have the option of seeing the doctor of your choice
with your insurance picking up at least part of the cost. Your employer wants its valued employees to have good health coverage Notice that it is an extreme rarity on this web site to find data
showing an insurance company that has significantly increased
its net reimbursements to doctors. Yet the insurance companies
keep raising your insurance premiums and then diverting millions
of your dollars out of the healthcare system and into their own
corporate profits (and into "golden parachutes" for their top
executives every time one of these programs gets "flipped" in
the next corporate takeover). Since the cost difference to your company between one insurance
plan and another is often minimal, it is hoped that you will select
the health insurance company that provides the better compensation
to the physicians who are actually caring for your valued employees. WHAT SHOULD Personally, I can no longer sit passively by and simply be a witness
to the demolition. I feel that I must do something to try to change the direction;
or I have no right to complain. This web site is just a fledgling effort so far; but if enough
other doctors respond by email with their support, suggestions, more insurance reimbursement schedules to post, and especially
with information about their own experiences with the insurance
companies, perhaps this site can grow into something that might
make a significant difference. MAKE YOUR OWN PERSONAL STAND I firmly believe that most of our patients will be willing to
resume writing checks for the full amount of our normal Office
Visit charges and routine lab work if they think those charges
are fair and if we present the facts of our cash-flow dilemma
to them in a gentle, concerned, and logical manner, making it
clear that we care deeply about them, but that we also must earn enough to cover our office overhead
and have something left over for our families. The only way any medical facility could possibly generate the
cash flow numbers to remain in business with the absurdly low
reimbursements of some of the managed care companies would be
to convert to some sort of "get 'em in - get 'em out", "take a
number, and we'll get to you when we can", "Sorry, time's up",
mass production cattle-call clinic. I believe that patients may
sample that kind of medical care once or twice, but that eventually
they'll want to come back to our warm, personal, on-time office
environment in which they feel that people really care about them
-- and they'll be willing to pay cash for that, just like they
used to do only five years ago. People will pay for good service
once they've rejected the alternative. That is why it's important
that doctors become partners with our patients on this issue rather
than just slapping them in the face by dropping off their insurance
plan without warning. It is partly for this purpose of gentle education of patients
that I have undertaken the publication of this web site and why
every doctor should consider referring every one of his/her patients
here for a calm, non-threatening introduction into the current
realities of medical practice from their Primary Care doctor's
point of view. OK, SO GIVE ME DETAILS The powerful insurance companies have brainwashed most doctors into believing it is they, the companies, that hold total control
over which doctors will be allowed to participate in their plans;
however, this concept lacks validity when it comes to Primary
Care doctors. Our patients are still free to make their own choice of their
Primary Care doctor because they have plenty of money in their checking accounts
to pay for our modestly-priced services (just as they did a few
years ago before managed care took over). IMPORTANT POINT... If a patient does elect to pay extra to go out-of-network to
stay with his or her long-time Primary Care doctor, then that situation is going to impact heavily on the patient's decision
at renewal time when he or she must make a selection between several
different health insurance choices for following year. The insurance companies know this and therefore definitely do
not want patients to go out-of-network. The following year, whether
a patient then (A) opts for a different, better-paying managed care plan their doctor does accept or whether they (B) change to a high-deductible plan (with lower premiums) or whether
they (C) decide to go for a tax-exempt Medical Savings Account program coupled with a very high deductible catastrophic insurance policy, their next insurance purchase will largely be guided by that critical decision they made many months before to stay with their long-time Primary Care doctor no matter what. It is this fact upon which we doctors must capitalize. If you have always done a good job taking care of your patients'
medical problems, treated each of them with warm concern, let
them know through your actions that you really do care about them,
had a friendly and attentive office staff, and see your patients
on time, most of those patients will not abandon you over this
fee-for-service issue if you present it to them correctly. If
you've been doing a good job of doctoring them, your patients
will be very resistant to the idea of leaving you for some stranger
and most will probably be willing to make a minor financial sacrifice
to stay with a doctor who cares and takes time with them, especially
after they're sampled their only alternative, one of the high-volume, impersonal cattle call clinics. The "re-education" of our patients back to fee-for-service actually
requires only a minimal effort if done correctly; and it will
yield very positive results, both for patients and their doctors.
This web site will do much of the "dirty work" for you if you
stress to your patients the importance of visiting it by saying
something like, "This web site will tell you what I would be saying to you if
we had enough time to talk about the problem in detail." Refer them to this web site Educate your patients and make them your allies. Explain to them exactly what's going to happen and how it will
affect them. Explain carefully that patients' actual out-of-pocket
costs will be only slightly higher for Primary Care than they
were before the return to fee-for-service. Also point out that
their out-of-pocket expense will be about what it was when they
had $500-1,000 deductible insurance before managed care took over
and wrecked the system several years ago. After they have reviewed the information on this web site, encourage
them to come talk to you about anything that is still unclear. WHATEVER YOU DO, It has been the historical pattern of these managed care plans
to "divide and conquer", to try to play one group of doctors off against another. Typically
they've pressured one group of surgeons or other specialists to
accept a fee profile somewhat lower than the going rate in exchange for receiving all of the plan's referral patients in that specialty area. Then
when the contract came up for renegotiation the following year,
they'd go to the docs who were "left out" the previous year and
ask them if they'd be willing to "under-bid" the other group to
regain access to that block of referrals. In this way the insurance
companies were able to play the specialists off one against the
other until, over several years, they'd succeeded in shaving the
fees down to such absurdly low levels that many of the most skilled and respected specialists are now on
the verge of going belly-up. The last thing the managed care companies want is for the oldest,
best-known Primary Care doctors (those with the confidence and security born of a huge, stable
practice full of loyal, long-time patients) to begin shifting their patients back to fee-for-service. If the "Old Boys" are able to pull this off successfully, it will set the sort of example for the younger doctors that the
insurance companies fear most, that Primary Care doctors have learned that they are more-or-less immune
to insurance company control. To avoid taking this risk, the insurance companies may be willing to try to "buy off" a respected
doctor they think is ready to bolt by offering him (and only him) more cash. I urge you, doctors, don't buy into this ploy. If an insurance
plan knows you are on the verge of dropping them, and they come
to you with a new "special pricing plan", ask them if the offered fees are the new standard schedule for
all the physicians in your community. If they tell you yes, then
ask them to email the new schedule to austintxmd@earthlink.net for public posting (or they can post it on their own company's
web site if they wish, and I'll set up a link to it from here).
Don't believe any company representative who tells you their new
fee schedule is universal until you see it posted right here. Please don't think I'm suggesting this out of some sort of grandiosity.
The last thing I want is for this web site to become is a clearinghouse
for the insurance companies to post their fee schedules. (What I enjoy posting is what the insurance companies don't want posted, not what they do want posted.) What I do want, though, is for new schedules somehow to become public knowledge and standardized
before we each must make our own decisions about whether or not
to accept them. I want a level playing field; so each doctor can make his own decisions for his own practice
knowing that all his colleagues are receiving the same treatment.
I don't want Primary Care to become "divided and conquered" as
the surgeons were. YOUNG DOCTORS especially will be tempted try to build up their practice volume
rapidly by accepting large numbers of patients from plans with
absurdly low fee profiles (the patients that more established
doctors have already turned down). I can't say this too many times: If you're losing money, you can't make it up on volume. There's always the temptation to look at your patient schedule,
see some gaps, and then rationalize that "cash flow is cash flow"
even if it's a low-pay patient; however, if you start accepting low fees now, you will never be able to
get rid of those low-fee patients later nor will you be allowed
to raise the fees you receive for treating them. Always remember that an insurance company is purely business,
and they will never voluntarily pay you one dime more than the bare
minimum they perceive you are willing to accept. Instead of becoming addicted to high volumes of low-paying patients,
concentrate on keeping your overhead low, live modestly, and grow
your practice slowly with good patients from the better-paying
plans. Avoid the temptation to sell your soul to the devil just
for more cash flow right now. Never lose sight of the fact that
having larger numbers of patients doesn't necessarily mean more income for you, but it certainly will mean having substantially higher office overhead expenses to service all those patients. GUARANTEED FAILURE A medical practice being built with large volumes of low-paying
patients will almost certainly FAIL because the office will never achieve a large enough cash flow
to catch up with the climbing overhead. And when the office finally
does fail, the young doctor is left with a crushing personal debt load that he/she will either have to repay or else declare personal
bankruptcy. Compare the reimbursement schedules ("Report Cards") on this web site. Figure out what your time is worth; and refuse
to work for less. If some insurance plan is offering less per
patient than you know you must make to stay in business, refuse to see their patients. Doctors, you'll never be able to make up for poor cash flow with
a large practice volume if all you've got are low-paying patients. All you'll get for all that added effort is more stress, not
more income. Draw the line now! Perhaps you think it can't become
any worse; but it can; and it will if we don't all take a stand
NOW. This means the company can drop you any time they want to, no
matter how good a doctor you may be, for no particular reason
whatsoever, if they just decide you're not willing to become a
"team player" in their corporate profits game.
DON'T RELY ON THE INSURANCE COMPANY'S PROVIDER LIST
If you are a patient considering a choice between several insurance
plans offered by your employer, keep in mind that the most well-known,
established, experienced doctors in Austin, those with the strongest
reputations, already have busy practices and accept very few new
patients. It's common sense to assume that these doctors, when
they do accept a new patient at all, will only choose to accept
a new patient from the better-paying plans and not from the poor
payers.
The managed care plans almost never delete a doctor off their list
of providers, even if the doctor dropped off the plan long ago. The plans
want their provider lists to look long and impressive, padded up with the names of the doctors with the best reputations in town;
so that they can sell their plan to your employer and then to
you. The truth of the matter is that most of the better doctors are unwilling to accept any
(or very few) new patients from the poor-paying plans (See "Report Cards").
A HEALTH PLAN THAT PROVIDES "OUT-OF-NETWORK BENEFITS"
When the managed care plans began, they enticed people to join
by promising them "out-of-network benefits" that allowed patients
to see any doctor you wished, even those not on the plan's "panel"
of doctors. It costs a patient slightly more to see an out-of-network
doctor, but patients still had total freedom of choice.
As the managed care plans have grown more powerful and arrogant, many of them have quietly dropped their out-of-network benefits;
so that you either have to see someone on their panel of doctors or pay the entire cost yourself.
Having out-of-network benefits is going to become very important
to you in the near future because many of the better Primary Care
doctors in Austin are on the verge of dropping off several of
the lower-paying managed care plans.
If your organization is currently offering you health insurance
only from one of the lower-paying plans, the odds are that the
people making the health insurance decisions are listening only
to slick salesmen from the insurance companies and simply do not
have available to them the sobering facts available at this website.
Please write a letter to your employer's insurance committee asking them to access this web site. It will be very helpful to them to have this rock-solid information
in hand the next time they are sitting across the desk from an
insurance salesman who is trying to baffle them with statistical
gobbledegook.
Please tell your friends and co-workers about this web site
We are all in this together, doctors and patients alike. If you
trust and respect your Primary Care doctor, if you feel comfortable
with him and his office staff when you are ill, if you do not
want your health care to deteriorate, please support your doctor.
He/she is not only your most important and permanent medical "Home
Base" but also your advocate and indispensable access link into
the entire health care delivery system.
If we do not all act together, the medical environment will continue
to deteriorate. If you do not make your voice heard now, you will have no right
to complain if you find that your medical care is becoming increasingly rushed
and impersonal, delivered by doctors (and doctor substitutes)
who are becoming more and more overworked, underpaid, always overbooked,
always late, always testy, and who seem to be rapidly losing interest.
No one wants that to happen, but it will unless enough patients
protest effectively.
Please be one more voice raised in protest right now, because
any additional deterioration that managed care is allowed to inflict
upon your health care is going to be a one-way trip for everyone.
If you are a member of your company's insurance committee and are weighing the merits of several competitive health insurance
plan proposals, you owe it to your employees to study carefully
this website's "Report Cards" of fee profiles paid to the doctors who are the actual providers
of care to your employees. If the costs to your company for different
plans are similar, it would be wise to select the plan that provides better reimbursements
to physicians since that plan will obviously be more likely to allow your employees access to the better-liked, long-established
doctors who are able to pick and choose which new patients they will
or won't accept.
If you are considering a company with poor (or declining) physician
reimbursements, you should have someone telephone a representative sampling
of doctors on that plan's provider list of "Primary Care" doctors
(Internal Medicine specialists, Family Physicians, and Pediatricians)
and ask each of them:
PRIMARY CARE DOCTORS
BE DOING?
There are three kinds of people:
Those who make things happen
Those who watch things happen
Those who wonder what happened
RETIRE EARLY?
Not me. I have not intention of retiring early. I love this work, and
I love my patients (my friends). Over all our years together,
my patients and I have become interwoven into the fabric of each
others lives. I refuse to unravel that beautiful and treasured
tapestry by quitting medicine, but the time is rapidly approaching
when I will have no alternative but to drop out of the lower-paying managed care plans and go back to
simple fee-for-service practice for those patients whose employers leave them stuck with bad
health insurance. Perhaps some of these patients will feel forced
to change doctors for financial reasons, and I will understand.
I'd prefer to continue taking care of all my patients, to keep working full days every day; but I have
too much respect for myself to work for peanuts; and I refuse
to become an indentured servant to the insurance industry. If
my practice becomes less busy because I reject the cheapest of
the insurance plans, then I'll just spend more time caring for
each of the patients who decide to stay with me.
If you are a physician who has finally grown sick and tired of
watching the joy and security being sucked out of your professional
career by Big Insurance, then now is the time you must take a
personal stand. You have all the facts right before you in the "Report Cards" on this web page. You can see which plans pay you fairly and
which don't. How much more will it take before you decide "enough
is enough"?
We doctors are all trained to be healers, not fighters. We are not trained in an adversarial profession
like lawyers and businessmen are. All of our training is about
cooperation against our common enemy, disease. We are not taught
how to connive and scheme and manipulate to seize control of something
from someone else.
Make no mistake about it, business is business; and the big insurance companies know how to play the "Business
Game" better than anyone. As long as they believe that we doctors are willing to keep selling
our unique and absolutely irreplaceable expertise to them for
lower and lower compensation, Big Insurance will continue to eat
away at us.
Several years ago when we began to accept discounted fees from
PPO's, we all thought, "Well, I guess this is about as bad as
it's going to get; so now I can get back to concentrating on healing
my patients." Wrong! As doctors remained focused on our business
of healing patients, the insurance companies remained focused on their own business,
too, how to make more money. And they're making piles of it by soaking the patients for higher
premiums at the same time they squeeze us with shrinking compensation.
This must stop!
BEGIN GENTLY
"RE-EDUCATING"
YOUR LONG-TIME PATIENTS
ABOUT YOUR INEVITABLE TERMINATION OF CERTAIN INSURANCE
PLANS AND RETURN TO FEE-FOR-SERVICE FOR THOSE PATIENTS
The days when patients didn't hesitate to write a check to their
Primary Care doctor for his/her services are only five years in
the past; but from all the insurance company propaganda one would think
that those days are gone forever. I believe that all the propaganda
is just that, propaganda, meant to brainwash doctors and patients
into believing that they have no alternatives; but that's not
true.
HOW DO I DO IT?
THE OBJECTIVE
HOW CAN THAT BE ACCOMPLISHED?
1. Let patients know that a serious problem exists with managed
care in general
Strongly encourage every one of your patients to visit this web
site
2. Inform patients about the details of the problem
Refer them to this web site
3. Inform all patients of the possibility that some may be forced to return to fee-for-service care with you depending
on their health insurance plans.
4. Supply patients enough information that they are able to figure out in advance which plans are likely to be the first affected and why.
Refer them to this web site
5. Once you've made the decision to drop certain plans, you must
give patients ample advance warning of any proposed change that affects them.
Send each affected patient a letter, explaining the change you
are planning and invite them to come in to talk you about it at
no charge.
Stress to patients that you are dropping their health plan --
you're not dropping them.
6. Whatever you do, don't blind-side your patients. That's how you could lose them.
7. Stress to your patients that the grossly inefficient, greedy,
impersonal managed care companies are to blame for the problems
and changes, NOT their doctor.
Refer patients to this web site and allow the FACTS to do this "dirty work" for you while you "Take
the High Road." It is best that you not criticize any specific insurance plan
yourself because you don't want to burn any bridges with that
plan in case they wise up and begin paying fair reimbursements
in the future.
8. Write letters to the affected managed care companies advising
them that you intend to drop off their plan.
Present your decision in purely businesslike terms, laying out
your reasons clearly. Avoid emotionalism or anger which have no place in a business
transaction. Remember that the company officials are businessmen who get in and out of bed with each other constantly
with no hard feelings - they accept it as a fact of business that change happens all
the time, and that business decisions are based on pure numbers.
These guys flow like mercury into the next groove they perceive
to be to their advantage, and they will not be surprised that
you have chosen to do the same thing. Don't say anything that might burn your bridges with any insurance
company because you never know when their reimbursement schedule may
improve, and you want to retain the option to re-up with them
if the conditions are favorable. They're not going to "blackball"
you from future contracts unless you behave like a jerk.
9. Gain confidence and have the courage of your convictions
Once you've dropped a plan or two and discover that the sky, in fact, doesn't fall, then you will be more confident about how you handle your future
relationship with other managed care plans whose fee schedules
fall in the gray zone between the top and the bottom on this web
site's "Comparison of Insurance Companies" table.
DON'T "CUT A SPECIAL DEAL" WITH AN INSURANCE PLAN
It has come to my attention via email from a colleague that certain
managed care plans (we won't name them until we've got rock-solid
written proof) have recently been hinting that they might be willing
to offer "special" (higher) fee profiles to certain individual
Austin Primary Care doctors who were threatening to drop off their
plans because of the low reimbursement profiles. If this proves
to be true, it certainly doesn't pass "The Sniff Test" -- we know what the companies are trying to do... "divide and conquer".
SOMETIMES YOU MUST JUST SAY "NO"
It goes against everything doctors believe to say "no" to a new
patient who is ill; but say "NO!" we must. I'm not advocating that any of us should turn our back
if a genuine medical emergency exists. Of course not! However,
none of us is ethically obligated to accept a new patient with
a sore throat or some other non-life-threatening condition of
he or she has lousy health insurance. As a Primary Care physician,
once you agree to accept a new patient, that patient is likely
going to be coming to you for many years; so be very careful not to allow your practice to become overburdened
with low-payers.
Doctors are not permitted to unite to "set fees" under threat
of antitrust litigation (don't the insurance companies just love
THAT!). Therefore each of us must decide individually upon some
rock bottom fee profile we are willing to accept and then refuse
to accept patients from any plan paying even a penny less (yes,
the insurance companies will even try to sneak the fees down penny
by penny if they must because even pennies will add up to more
millions of dollars of profit to them in the long run).
We will always have among us those few doctors who "just don't get it", who will try to build their practice by accepting teeming masses
of patients from the lowest-paying insurance companies, but there is simply no way they can deliver quality care if the bulk
of their practice is low-pay. The few patients they might have from the better-paying plans
will soon become dissatisfied with their rushed, impersonal care
and change to one of the more attentive doctors available to them
through their superior health insurance program. The inevitable
fate of doctors who accept a lot of low-pay patients will be a failed medical practice; so the majority of us who are still committed to excellence must
not be distracted or lose our resolve by their presence in the medical marketplace.
It is critically important that physicians develop some sort of
mechanism for
COMPARING NOTES
Without giving the appearance of "Fixing Prices."
Please read my comments entitled
"COMMUNICATION BREAKTHROUGH?" (click).
BE CAREFUL WHAT YOU AGREE TO IN A MANAGED CARE CONTRACT
Managed care contracts sometimes contain wording that will compromise
your ability to take the best care of your patients. Read the fine print in any new contract carefully. If you see any of the stipulations
below, it's very likely that the plan intends to do some things to your patients with which
it believes you will not agree, and you should reject it:
.
CLAUSES TO REJECT
____
EXPLANATION
Anything that restricts physician-patient discussion of all medically
appropriate treatment options
Avoid any contract language that prohibits or restricts you in
any way from informing a patient of all medically appropriate
treatment alternatives; for example, language that prohibits the
discussion of experimental therapies or other services not covered
by the plan's benefit package
.
Any clause the requires you to consult with the plan before discussing
all medically appropriate treatment options with your patients
This would mean that you couldn't discuss any treatment options
with your patient until after a recommended diagnostic or treatment
service had been approved by the plan's utilization manager, medical
director, or other plan representative (maybe a clerk with only a high school diploma)
.
Non-disparagement clause
Such contract language would prohibit you from making disparaging
remarks about the health plan, or any remarks that might undermine
a beneficiary's (or the public's) confidence in the plan. This
would preclude you from expressing any disagreement with the plan's
coverage or utilization decisions regarding a course of treatment.
.
"General" or "business" confidentiality clause
This would require you to maintain the confidentiality of "proprietary"
information such as the plan's payment or incentive structure
or medical management criteria or protocols. In other words, you couldn't tell a patient you'd known for 20 years the truth
about what their health plan was paying you.
.
Non-solicitation clause
This kind of contract language bars you from "soliciting patients"
for another health plan. In other words, you couldn't tell a long-time patient that you were about to quit
his health plan and that he might consider changing to another one that you accept.
.
"Without cause" or "at-will" termination clause
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PLEASE TELL OUR COLLEAGUES ABOUT THIS WEB SITE
PLEASE TELL YOUR PATIENTS ABOUT THIS WEB SITE A doctor emailed me a great idea that goes even one step further. He's started posting printouts from this web site, especially the "Comparison Table" and "The Latest Bad News", on a bulletin boards in his waiting rooms where patients have a few minutes to read them. He reports his patients have been especially interested in talking about the articles on the Humana/PCA, the NYLCare/Ethix takeover, the Aetna and Blue Cross debacles, and what these events may might mean to their health care. He says there's also been a lot of interest in the "Silent PPO" piece. Thanks for the suggestion, doc. For all of you who've written with suggestions and offers of support, please "keep those cards and letters coming." We'll post the best ones (click) for everyone to see.
If you have a web page for your medical practice,
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I'm a doctor, and what I really enjoy doing is taking care of my patients. I'd like to retire from web publishing as soon as I can get some bigger organization with more resources to take over the job I've started. Doctors, please help me. Please send an email to every address below that pertains to your specialty. Ask the officials of your professional organizations to view this web site for ideas and then publish a web site like it for the benefit of your specialty. Be sure to mention the URL (http://home.earthlink.net/~austintxmd). This is the kind of service we are paying for with our dues to our medical organizations; yet none of them (locally or nationally) are giving us the information we need to make intelligent decisions about how to resist the managed care cancer. Every medical organization has been tiptoeing around this issue for fear of being accused of "price-fixing." All they do is hold their heads, hold our hands, pat us on the head, and then give us watery Pablum about how to practice medicine under managed care, nothing about how to stop the spread of the cancer. Although it's being left up to each of us to make our own decisions about how to run our own practices and fight this monster on a one-to-one basis, I cannot think of any legal reason why our professional organizations cannot make available to all of us, in easily digestible form, the information that each of us already has in fragments from our own office bookkeeping records and from the media.
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| We're talking survival here, guys. WAKE UP! These insurance guys are predators, and they're going to eat us up if we don't start fighting back. |
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Anything we've already lost up to this point is probably gone for good. If we allow the insurance hyenas to continue intimidating us and gnawing away at our flesh bite by bite, we will have no one to blame but ourselves for the next round of losses that are sure to come. It's time for us to say, "Enough is enough!" and start biting back.
WE ARE IRREPLACEABLE,
WE ARE THE SYSTEM
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