Have you gone to the doctor recently? I mean in the last couple of years or so. Think about what you saw while you were there.
My son has had two visits over the past 6 months, one to his pediatrician (PCP) and one to his psychiatrist. My son’s PCP accepts a wide variety of insurance plans (but not SCHIP) and his psychiatrist doesn’t accept any insurance. You pay her and file with your insurance company afterward for reimbursement.
Visit with the Pediatrician (Primary Care Physician)
When we got there we checked in at the reception desk where they verified all our personal information and insurance or other method of payment. We were paying cash. Some doctors or clinics require payment before you see the doctor. This one doesn’t.
As we checked in, I saw a sea of clerks behind the desk and in the file room, which they have walled off with windows. I guess that is so you can see how many people have to get paid when you use their services. We waited for about 10 minutes and were called to the back by the nurse. The doctor saw my son and we were in and out in about 25 minutes. As we left, we stopped by the payment desk and paid for the visit. We got a 25% discount off the price because we paid for the visit in full that day.
The quality of care with my son’s PCP is excellent. This PCP and the other doctors in the group have been my son’s pediatricians since he was born and I have no intention of changing doctors. My son is on SCHIP, so we have to pay the doctor visit bill, but they cover his prescriptions in full. This group doesn’t accept SCHIP.
There are 3 doctors in this group and each has one assigned nurse. There is at least one float nurse and usually there are two. That nurse handles phone calls, gives routine immunizations, fills out school health forms and covers during breaks. That staff count comes to 7-8 professionals in the practice to see and treat patients. That office area also has two other groups of pediatricians with 2-3 doctors each with the same ratio of nurses. All use the same reception desk and file room.
There are at least 15-20 clerks behind the reception desk and in the file room at any given time at that clinic office. These clerks don’t handle the actual billing. They handle collecting the required information, calling insurance companies for pre-authorizations when needed, and taking co-payments or deductible payments from patients. Each area of medicine has groups of doctors and there own clerks and file rooms. The more doctors in an area of medicine in the clinic, the more clerks required.
There is an entire department in the clinic that does all the actual billing and insurance payment collection. There are about 50 employees there. All they do all day is fill out insurance claim forms from the information collected by the clerks in the doctors’ offices and send them to insurance companies for reimbursement. Forms go out by postal mail or by computer. Payments take on average 4 months to come back. Medicare is the only exception. They pay in about 45-60 days.
The clinic has more administrative employees related to insurance billing than patient care employees and doctors. Dealing with getting insurance companies to pay requires an entire department of its own. The cost to run such a department is staggering, but less expensive than for a smaller group of doctors to handle it themselves. Certain administrators specialize with a few insurance providers so they can put claims through 2-3 times faster than if they didn’t specialize or have a large staff.
When our doctors’ group joined the clinic after being independent for decades, I asked why. They said it was because of the increasing administrative overhead. The clinic offered the entire administrative staff they needed at a more affordable and predictable price than they were paying. It comes with renting the office space, too. They moved so they could have predictable expenses every month and get out from under the pile of insurance issues they had to deal with before they moved.
The doctors each take a day off a week now that they moved to the clinic. They can afford for each doctor to work 4 days a week. All the pediatricians in town associated with certain hospitals rotate 24 hour on-call duty, so each doctor is only on call once or twice a month.
They also use the hospital’s nurses exchange to screen after hours calls. The nurses are able to authorize trips to the emergency room for non-life-threatening emergencies, prescribe certain medications, forward calls to the on-call physician and give advice. They report all calls to the patients’ doctors daily. It’s an excellent way to triage patients and make the most efficient use of all available services while getting each patient the care they need quickly. The hospital provides the service with little or no charge to doctors who use it to reduce the number of unnecessary ER visits.
The bottom line is with large clinics that have a large administrative staff to handle insurance claims, doctors make more money and may get more days off during the week than if they remain in independent practices if they accept insurance as payment.
Visit with the Psychiatrist
There is a stark contrast between the PCP visit and the visit to the psychiatrist.
We walked into her office, checked in with her receptionist and paid our bill. This psychiatrist requires payment before you see her. If you need a payment alteration, it will be handled after you see the doctor. They accept cash, checks, credit and debit cards, and money orders. They do not accept insurance.
We saw the doctor, got my son’s prescriptions and were on our way in about 40 minutes total.
There is no sea of clerks, just one receptionist. The office has two nurse practitioners and a few mental health counselors along with the doctor. This doctor has her own building which is paid off. She only sees patients 4 days a week, and that extra day is usually a day off that she spends with her family.
She used to belong to a small clinic, but didn’t like dealing with insurance and paying ever-increasing rent. She felt it interfered with the quality of care she was giving her patients. Our check-up visits are 20 minutes now instead of the 15 minutes they used to be. When I need to get my son in on short notice, she has 30 minute or longer appointment times available. If I have to call her after hours, she calls back within about 15 minutes, and she is the one on the phone.
This pediatric/adolescent psychiatrist can demand up-front payment and get it because she is one of the best psychiatrists for kids and teens within 100 miles. She is worth every penny and then some.
There is a huge difference in quality of care provided by pediatric psychiatrists who take insurance and the 1-2 who don’t. Most of our experience with psychiatrists who took our insurance didn’t seem interested in talking with me or my son. One only spent 5 minutes with us and handed us prescriptions without even asking how he was doing. We changed doctors when we were assigned that one by our insurance company. We went through 3 doctors before going out on our own and paying cash.
I haven’t found quality of care issues to be the case with psychiatrists who treat adults. I still see the same doctor my insurance assigned me to even though I no longer have insurance. Pediatric psychiatry takes special people with special talents who can relate to children and teens, and diagnose them properly.
Since our terrific pediatric psychiatrist wasn’t on the provider list of the insurance company, they wouldn’t reimburse us anything for visits with her. They did cover prescriptions with co-pays.
Now that my son is on SCHIP, they don’t pay for visits, but they do pay for his medications in full–no co-pays. That’s very important to us because he must have his medications and they cost about $200/month. Now that his condition is under control, we only have to see the doctor every 4-6 months.
I don’t have any insurance at all and I have to pay for my doctor bills and medications out of pocket. My medications cost about $280/month. It’s often cheaper than that if my doctor has samples of the name brand drug I take. Then they only cost $150/month. I have to pay for the generics I take. Pharmaceutical companies don’t give samples of generic drugs to doctors. One of my generics is $10, the other is $140. Generic drugs shouldn’t cost that much.
It is becoming very clear to me that private health insurance companies and the price of prescription medications are a large part of the health care cost problem. Insurance companies already ration health care by denying and approving payment for medications, doctors, tests, procedures, and surgeries. You’re free to have whatever treatment you desire, but they may or may not pay for it. If you can’t afford to pay for expensive services that you need on which coverage has been denied, your health care has been rationed.
What value do private health insurance companies bring to the health care table? What value do they add? I’ll discuss this question in a future post.
What have your recent experiences been with your doctors? What have you noticed about the way the office operates? Do you have insurance and if so, what do they cover? Have you had to fight with your insurance company? If you don’t have insurance how are you managing? Let us know in the comments.
August 23rd, 2009 at 7:07 pm
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August 24th, 2009 at 12:56 am
I am a Tricare Prime patient, which is the free medical coverage offered to active duty armed forces personnel and their dependents. This is the closest thing in practice to a government-run health plan in this country.
I have an infant daughter who is assigned a Primary Care Manager who is supposed to manage her health care. My daughter has already had two different PCMs during her six months on Earth, and has only ever seen one of them. Normally, she has to see a nurse practitioner.
When we try to schedule her well-baby visits, we must call at least three but no more than four weeks in advance, and we still never get to see an actual doctor. We show up for the appointment 15 minutes early as is required (otherwise your appointment will be canceled, even if you are prompt), end up waiting for 45 minutes in a roomful of sick children, then are rushed back into an exam room, where we wait for another 20 minutes or so. The harried nurse comes in, quickly checks her and kicks us out in less than 15 minutes. We then proceed to the immunization room where a none-too-gentle corpsman quickly jams several needles into my daughter’s legs, without the courtesy of telling me which is which so that I can accurately monitor adverse reactions and report them at the next visit. If I complain to the clinic ombudsman about the (mal)treatment my child gets, nothing is done (except that they have an even harder time trying to fit her in for her next appointment!). Given that we never see the same doctor/nurse twice, there is NO continuity of care. Wouldn’t I love for my child to have the same pediatrician for even six months at a time? I feel really blessed to have made it all the way through a pregnancy with the same OB. That’s pretty sad.
If my poor kiddo gets sick from being around a dozen kids with Swine Flu, and I call to make an appointment, I can expect to wait three days before she can see a nurse (where the hell are the doctors, anyway?). If it can’t wait, I can take her to the ER. However, if I take her to the wrong ER, or fail to get Tricare permission within 24 hours of taking her there, I will be stuck paying the whole bill. If I take her to see a pediatrician out in town? Stuck paying the whole bill. I can request a transfer to a civilian care provider but it will be denied as we live within 50 miles of a military treatment facility. If we are vacationing and she runs a fever and needs to see a doctor, I have to take her to an ER and get permission within 24 hours, or they won’t pay for it.
For prescription drugs, a very narrow range of formulations and pills are covered. If you have GERD, you get esomeprazole. Insomniacs get Ambien. Ortho-tri-cyclen is your triphasic birth control. In very rare instances when people have life-threatening allergies will an exception be made, but it has to be fulfilled by an outside pharmacy where a copay applies, and it is not transferable from duty station to duty station. The little upshot is that multivitamins and motrin are free.
Your medical records are property of the US government, and if you want a copy of them, submit a request and prepare to wait at least 30 business days. You may not photocopy your own records. Your records are often irretrievably lost when you move. Basically, memorize your blood type, your allergies, and any other information that may be helpful to any future doctor who will treat you. Prepare to have unnecessary and redundant labs performed when the doctor doesn’t believe that you are O- and do in fact need Rhogam after delivering an Rh+ baby. Expect an extra flu shot, and be willing to fight for your tetanus booster!
As tedious as this is, it’s a far sight better than the VA. The VA simply doesn’t provide care at all.
August 25th, 2009 at 3:45 am
Hi Tricare Beneficiary. Thank you for posting your story. I can relate pretty well to it and know your frustrations in dealing with military health care. You get health care and it is usually what you need, you don’t have to pay for it, but the quality isn’t what you would get in the private sector. There is almost no continuity of care because of the way their system works. It needs reform, too, but different reform than the private sector’s system.
My experience with Tricare is it’s like a really strict HMO, and if you don’t follow all their rules, you will be denied coverage. HMO’s aren’t so prevalent now because we refuse to pay outrageous premiums, deductibles and co-payments and have the insurance company tell our doctors what they could and could not do. Doctors had to get permission to practice any kind of medicine, even real emergency medicine in life-threatening situations. That was the start of the health care providers taking care of insurance claims for patients. That started the need for doctors to have to hire so many administrative employees to handle all the new paperwork that was thrust on them that the patients used to have to fill out and file themselves.
I was a Navy brat, born in a Naval hospital. They saved my life and my mom’s, but I hear it wasn’t pleasant. We moved so much that I don’t have medical records from before I was 19, except my shot records. We had to keep those with us at all times. Tri-Care was no fun when we had to go to the doctor on base. It’s fine if you’re outside the 50 mile limit because you can choose your own doctors. Our corpsmen were over-zealous about all immunizations. I ended up with a tetanus shot nearly every year whether I needed it or not, and when they heard their might be sewer leaks in our local neighborhoods, they vaccinated us all for typhoid.
Back when I had to go to TriCare on base, I saw physician’s assistants. Nurse practitioners replaced them, and I’d rather see an NP than PA. I can’t say they ever made me sicker or didn’t help me, but it was typical military life–hurry up and wait. And be ready to talk fast about any previous treatment you’ve had for a specific illness. We didn’t have much choice of meds either, but back then there were a lot fewer meds to give and they weren’t so expensive like they are today. I was beyond needing well baby care, and I don’t remember my parents saying much about problems with well baby care when I was a baby. I was high risk and was seen very often, at least once per month. I only weighed 3 lbs 5 oz when I was born in 1960, a birth weight that usually didn’t survive back then.
My sister was born while my dad was out on reserve duty going to college on the GI Bill before he went back on active duty. My mom had the same OB during her pregnancy with my sister. After that, we had one family doctor who saw all of us, and he was a former Navy surgeon who went into general practice and was an excellent doctor. But that was back in the 60’s when a lot of docs went into the military for their internships and residencies. It paid better, had lower living expenses, and trained surgeons very well since we were in a war at the time (Vietnam).
In the late 70’s, my dad had diverticulitis that required surgery and the only military hospital available in New Orleans at the time was the VA hospital. It was horrible while we were trying to get him properly diagnosed (they didn’t have CT scans or MRI’s so that diagnosis was a difficult one if there wasn’t a blatant rupture). That took 6 weeks before they finally figured out what was wrong and what he needed. Once we had a diagnosis, he got excellent care at the VA. They performed his surgery and he recovered faster and without secondary problems like I had when I had the same thing happen to me. I actually had a rupture with lots of pain, high fever, and was admitted to one of our better private hospitals under employer insurance, Aetna I believe. I had the surgery, got an incision infection and had to heal with the skin open (hideous, huge scar). I got blood clots from being in bed with no anti-embolism stockings or leg circulation pumps. I was on warfarin for 5 months (Coumadin). I also had to have major hernia surgery 13 months after the initial operation. I was lucky not to end up with a temporary colostomy.
I did end up laid off from my job after two major operations and about 6 months total of missed work in a 16 month period at the end of 2003. Everyone who had gotten very sick had been laid off within a couple of years of their illness. They wanted us out of their risk pool. They had to extend COBRA to us for 18 months, but we had to pay for it, and then we were off their insurance. I’ve been uninsured ever since COBRA ran out. My son is on SCHIP, which is a very decent program. It has its problems, but for the most part, it’s a good program.
I’m for a public option that is like Medicare, not Tri-Care. Most everyone on Medicare loves it and wouldn’t cancel it unless it was taken from them. My mom gets Medicare, LA State Group Benefits from her job, and her third insurance is Tricare for Life. With retirees on Medicare they reimburse after all other insurance has paid. She pays nothing out of pocket.
If we end up with a private insurance national exchange that can’t deny us coverage for pre-existing conditions and really has to compete for our business, it might bring prices down quite a bit, although I don’t think it will be as efficient as making a public insurance option available. Still, major reforms of the private health insurance companies, especially breaking their monopolies in many states, will drive costs down. Insuring most people will also spread the risk around better. Even though everyone won’t buy insurance, it should still be required by law like car insurance. If it’s affordable young, healthy people will buy in and lower overall risk which will drive costs down. Focusing on well care, check ups and early diagnosis and treatment, and better management of chronic conditions will definitely save money in the long run.
Even though the GOP is trying to scare the hell out of everyone about it, if more people stepped up and made their end-of-life wishes known and have the proper documents drawn up (ie living wills), it will also save a lot of money. Many people who are at the end of their lives, miserable and in pain and would rather be in hospice with good pain relief and DNR orders so they won’t be given the maximum level of life-saving treatment if they don’t want it. Maximum treatment does cost a lot of money, but it’s not about the money, it’s about what the patient wants to happen at the end of their lives. Many would prefer hospice, and pain and symptom relief care than maximum treatment. But without a living will and an advocate to enforce it, the standard procedure is to provide the maximum live-saving treatments. When I was a nurse’s aid, we resuscitated a lot of very elderly and sick people who didn’t have DNR orders. They would wake up in ICU and ask why the hell we didn’t let them die. Our answer was always the same; they hadn’t signed a do not resuscitate (DNR) order. They didn’t tell us to let them go, so we couldn’t.
August 31st, 2009 at 12:43 am
[...] Read the rest here: More administrators than doctors and nurses [...];. All the best!!