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Our 21st Century Healthcare System: Change or Chaos

Remodeling our health care system for the 21st century will be a challenge to say the least.  We do need to make changes to our current system. Change could be good,if you have a game plan. First you need to know how the system operates from the clinicians to business aspect of health care to the insurance companies.  I will give you a glimpse  into world of outpatient centers, which operate differently from a hospital setting.
First I will like to point out, insurance companies are in the driver seat. Insurance companies set the rules and the rules can change any time, without reasonable warning. Their reasonable warning could be an announcement in a newsletter that nobody reads or a letter that gives an unimportant appearance. When policies change, its usually in favor of the insurance company and by the time a clinician's business department adjusts to the change, the insurance company has save money and the practice has lost money.
Another important issue to understand, clinicians do not have due process to challenge insurance companies decisions concerning treatments or payments. Yes in some states you can report an insurance company to "Insurance Commission", sometimes the clinicians win,most of the time the insurance company wins.  Actually the patient is the advocate for the clinicians and for themselves.  Insurance companies have somewhat of an interest in keeping the patient a little happy, after all the patient (employer) has the contract with the company. What do you about this comment, your staff calls to verify the patient's policy and possibly obtain either an authorization or referral for treatment, the insurance  will make a statement "this is not a guarantee of payment".  Also, what company does not pay an invoice in 30 days, you guess it, the insurance company.
I don't think the general public realizes that most clinician's fee schedules from the insurance companies have either decreased or stay the same in the last 10 years.  Medicare has raised their fee schedule in the past, now its looking to decrease the fees by 10%.  By the way Medicare is the best payor for some clinicians.
Operating a health care practice is expensive, forget about the clinician's salary, there's rent, employees salaries, benefits for the employees, usual office expense, medical supplies, equipment, professional and business liability, and host of other expenses. The bottom line of a health care practice is gray , its not like the bottom line of a general business, thats more black and red.
In the future I will write articles concerning all aspects of health care, clinical, business and the insurance companies.  In some instances I will give my recommendations for remodeling our system. Changing our health care system will have a great impact on our health and the health of the economy. We need to be smart and not put the horse in front of the cart as we did with our food system.

Do You Really Have Secondary Insurance Coverage?

Medicare patients come into a medical/health care practice feeling pretty confident that they will not incur a financial balance.  I always hear don't worry I have secondary insurance, they will pick up my 20% co-insurance.  This was true back in the mid 90's but things started to change around 1998. All of sudden a couple of insurance companies  (secondary policy) were denying the claims. The explanation of benefits would read that the company follows Medicare's fee schedule. Well great , Medicare 's fee schedule  recognizes a  max fee for a certain code and will be pay 80% and the remain 20% is the co-insurance. To step back a little, insurance companies such as Aetna, Cigna, etc. offer secondary insurance to seniors, meaning they will pick up the 20% of co-insurance. If there is a financial limit by Medicare, the secondary would cover the Usual Customary Fee.  All of a sudden, starting around 1998 some secondaries started to  test a new policy, "we recognize Medicare fee schedule and Medicare paid the full amount" ,
claim was denied. The billing and collections department would call the insurance company to argue this new policy, guess who won the argument.  Now we had to explain to our patients that they no longer had a true secondary.  This was a no win situation. Now having 20 - 20 vision to the past, the patient needed to call the insurance company and argue their own case.  After all it's the patient who has the contract with the insurance company and could threat to canceled their policy.  I'm sure the insurance companies did a study concerning the senior desire to fight.
Now,the year 2008, there are very few insurance companies today who pay the 20% co-insurance, deductibles and financial limits by Medicare.  We have seniors who might  have 2 secondary policies. It's a shame and sad when you have to explain to the Medicare patient that their so-called secondary will not pay their deductibles, co-insurance or financial limit.  At first they do not believe you until they receive the explanation of benefits from the secondary.  They either become angry at the insurance or they stay in denial and blame the practice for poor billing.  Again the patient becomes angry but they do not cancel the secondary policy.  Boy do the insurance companies know the psych of the senior.
Its wrong that people spend alot of money on secondary coverage and do have a true secondary.  In the coming years Medicare will be cutting fee schedules, not so much services, that would be suicide by our government. We will also see higher deductibles and financial limits on services.  Yes the baby boomer generation will placed an enormous strain on the system.  Our society should take some financial responsibility for their health care expenses. At the same time both insurance companies and the government should be honest with us.  Explain they positions and work together.  We can develop other alternates but we need to know the truth.  As a society we also must take responsibility for ourself and stop expecting the government to always pay our way.  We can face the challenges ahead, only if we control our destiny.  Do not let the government pay your way.  Remember the famous saying by JFK " ask not what your country can do for you - ask what you can do for your country".  We need to find our soul and be responsible for our lives.  We need to make the our society great again.  We can do it, not the politicians.

   

Changes in Medicare For Physical Therapy

As of July 1, 2008 Medicare patients might have a cap on their physical therapy visits.  Right now there is a financial cap but there are diagnoses that are exceptions to the cap.  Medicare also plans to decrease the physical therapy fee schedule by 10.6%.  There is hope if Congress decides to either eliminate the cap or keep the diagnoses exceptions.
It's interesting, physical therapy is cost effective but yet Congress wants to have a financial cap?  Yes the baby boomer generation is approaching quickly, 2011 and there will be more patients.  The typical Medicare patient usually has more than one injury and in most cases the problems are complex. It's not like treating a 35 years old person with shoulder pain.  The Medicare patient will come in with shoulder pain,  a decrease in range of motion, loss of function and neck/back pain.  Now to treat the patient  possibly in 18 visits (average amount of visits to reach the cap) is difficult to say the least.  The person will only receive those 18 visits for the whole year. Now what happens when the Medicare patient finishes their physical therapy treatment and still has pain, decrease range of motion, and unable to perform daily tasks pain free? Well chances are they will visit the orthopedic surgeon who will perform surgery to help the patient regain their function. Yes another problem arises, the Medicare patient needs another round of physical therapy to regain their motion and strength. yes a vicious cycle has emerged.
I understand our government is worry about the financial strain the baby boomers generation will place on the Medicare system and rightly so.  First,  there will be some Medicare Baby Boomers who will be working, which makes them and their spouse not eligibly for Medicare benefits.  Another idea, instead of capping physical and speech therapy at $1,810,  we should cap the daily reimbursement rate. The daily rates would be different in each state due to the expenses of operating a practice. Example the rates could be set between $65.00 - $90.00 and evaluation/re-evaluations will also be paid at a set rate. 
The government can oversee utilization reviews with their very powerful software systems.  The professionals will also oversee their own utilization and use the right judgment for discharging the patient.
We need to look outside the box and not only look at short-term results.  The government seems always to look at the small picture instead of the big picture.  It seems politicians do not have the ability to look beyond today.

I truly believe society is the change maker not the politician. Politicians only react to our needs and wants.in the future we will need to make tough and hopefully creative ideas to change our world.