Cash Flow

Fountain at the Alamo in San Antonio

“You tell that doctor to write me a prescription for something affordable!”

*Click*

My medical assistant glanced up at me with a shocked look on her face. There was no need to repeat the conversation. I had heard every word.

“That does not make any kind of sense. It is a generic medication. It should only cost $40. Max. Call his pharmacy and find out what that med is going to cost him there.”

Later in the day I read the computer message that said it was going to cost $340 for a one month supply. Hell. I wouldn’t even pay that. 

I typed out a quick message and routed it back, asking why it was going to cost that much.

It is the brand name. If you want them to fill the generic you have to write for the generic. 

Except that I HAD written for the generic. I always write for generic. 

I sent back a stongly worded message pointing this out and telling them to fill the frickin’ generic. 

This was followed by a string of other patients with similar complaints all from the same pharmacy chain. Insurance companies refusing to cover prescriptions that patients had been getting without issue because the pharmacy chain was filling brand name instead of the generic option. It makes them more money. I would have never known this was occurring if the insurance companies had not denied coverage. 

From a drug coverage standpoint we love to hate on insurance companies but pharmaceutical company and pharmacy shenanigans are one of the reasons healthcare costs in the US are skyrocketing out of control. 

So I tell patients to be aware of what they and their insurance companies are paying for. If there are significant changes, please ask questions. Shop around to other pharmacies. The variability of cost from one pharmacy chain to the other is astonishing. AND, talk to your doctor. The only way I find out about these kinds of things is from patient complaints.

Just maybe don’t yell at my staff… 

Veracity


He chuckled to himself. Potassium level?

Let’s make this one 6.5….

He hit enter then scanned down the list. 

Ahhh… a 90 year old woman. Perfect!

This time he picked the sodium level. 

126

In thirty minutes he had changed the results on over three dozen patients. Just one or two per provider, not enough to cause much of a stir…. Since none of the docs at the various system clinics spoke to each other.

*******************************

Potassium level 6.5? No eveidence of hemolysis noted. Damn.

She sighed and dialed the patient’s number, hoping he would pick up.

“Hello?” a male voice said

“Mr. James?”

“That’s me…”

“This is Dr. Stephens. I was calling to discuss your lab results. Do you have a second?”

“Sure, Doc!”

“Your potassium is showing as rather elevated. Most of the time this ends up being an error but at this level, if it is true, it can kill you. We need to get it rechecked. The best place to do that is the ER. They will recheck the levels and do an EKG and if it is really elevated they can bring it down.”

“Are you sure?”

“Yes, sir. I know going to the ER is not a cheap proposition but I don’t feel like at this level we have much of a choice.”

He sighed audibly. “Ok, Doc. If you say so. Should I go right now?”

“Yes. I’ll call ahead and let them know you are coming and why.”

She had alerted the lab to these abnormal results several times. Each and every time it seemed they were proven false. It had been occurring since the mandate that all providers had to use the system laboratory instead of sending their samples to an outside place. Invariably she was told it must be a problem with the way staff was drawing the blood. 

Only it wasn’t… She knew that was not possible.

*********************************

The board gave a standing ovation. Revenue for the system had reached an all time high. It had been a banner quarter. Things had been looking grim for so long….

A nondescript figure in a dark suit with a light blue silk tie sat silently in the corner, arms crossed, smiling to himself. 

Impact: Chapter Seven

Chicago in lights

“Next.” 

I stepped forward to the granite counter top and managed a weak smile. The woman in the bank’s uniform half-smiled back at me. Her striped blue and red scarf was tied jauntily at her neck.

Like a flight attendant.

“How can I help you?” She sounded bored. In her mid fifties, the woman had amazing hair with just the right amount of wave and body. 

I felt the familiar envy. I stared at that hair, wishing my own head was not covered with the flat, lifeless, straight as a board hair I had been cursed with. It was a dull mousy brown until I started to dye it blonde. At least the blonde helped. Speaking of which, my roots were showing. I needed to make a hair appointment if I was going to have to start interviewing for jobs now.

Times of stress always left me to dwell on each of my own flaws. My thighs were probably going to come up next. Maybe the crows feet. I was getting old. I looked closely at the woman’s eyes. She had great skin, too. I focused on her chin looking for hairs. 

Please let there be whiskers. Please let there be whiskers.

Nope. Not a single one. 

Damn it.

“Ma’am?” Irritation was in her voice and any trace of smile had now left her face.

“Oh. Sorry.” I felt my cheeks flush. “I need to make a deposit.” 

I pulled the paper paycheck, my last paycheck, out of the envelope. “Wait. I forgot to sign it.” 

The woman raised an eyebrow and passed a ballpoint pen to me. It was attached to the counter by a chain that made a slapping noise with each stroke. Banks were always disconcerting… unearthly quiet despite the hard surfaces and volumes of people. I felt I was disturbing the peace just by scribbling my name.

I passed the signed check to the woman. Her name tag read Elyse.

She waited, expectantly. “Where’s your deposit slip?” She looked at me, incredulous.

It had been too long since I had manually deposited anything into my bank account. My checks had always been deposited electronically. 

“Um, I don’t have one.”

“What’s your account number?” I could tell she was holding back the disdain with great effort.

“You know what? I don’t know that either. I have my bank card, though. Can you pull it up from that?”

I pulled the card out of my keychain wallet and handed it over.

“Do you have some ID?”

I cringed self consciously as I showed her my awful driver’s license picture. It was from before the blonde. She nodded, handing it back, and I tucked it quickly into the safety of my billfold.

Curt typing ensued. Then a scowl at the screen. More typing. Finally, she looked up at me suspiciously. 

“It says here that you closed out that account yesterday.”

A wave of nausea came over me.

“What do you mean?”

“I mean that it says you were here yesterday and closed out the account.”

There was $20,000 in that account.

“Does it say if I took that money in check or cash?”

She manipulated her computer mouse and clicked twice.

“Cash.”

There was no way to trace it.

“What about my savings account?”

“Also closed out.” 

I had scrimped and saved, trying to accumulate enough to eventually retire, hopefully sooner rather than later. I didn’t know how long I could keep up working as an ER physician. They had a high burnout rate after all.

It was gone. Every bit of it.

What was happening to me? Should I say something? Report it to the police? 

“That wasn’t me,” I said softly.

“Customers are not allowed to cash out accounts, particularly NOT accounts that large, without notice and without proper ID. I can assure you that you did indeed close out that account.”

“It was not me.”

A “Hmmmf…” of disbelief was all she uttered. The woman offered no other explanation, no further assistance. 

“Can I just cash this check, then?

“Fine,” she said sharply.

“In tens and twenties, please.”

I weighed my options as I watched her count out the bills, one by one. Four thousand dollars was not going to last me very long. Not in Chicago. 

Not anywhere, really.

At least I had paid the month’s rent last week. I was good there. 

The wad of bills was thick. I registered that my work computer was still there as I stashed them at the bottom of my bag. That could be helpful. I wondered how long it would take for them to realize I still had the thing.

I walked the few blocks back to my apartment mulling things over. Who could I call for help? I needed advice. Six months ago I would have called my boyfriend. Well. I would have if my phone had been working, but now, even if we were still on speaking terms I realized I did not know his phone number. I had never had to know it despite texting and calling him thousands of times over the years we had been together. My phone made communication with him a no-brainer. 

There had to be someone else I could call. Surely. As I rode the elevator up to my floor, I wracked my brain but there was no one. I had no friends. Only work acquaintances. There was no one I was close enough to that I could call them up and confess that my world was falling apart. No one except for him. Having regular sex with someone allowed you certain lifelong privileges didn’t it?

Probably not, but I still had to try. 

Maybe I could look him up on the work computer if my password hadn’t been shut down already. Not his cell number, of course, but I could Google his office number. He’d be in clinic right now if it was not a hospital week. If wifi was not working in my apartment, and something in the pit of my stomach told me it would not be, I could find a Starbucks somewhere… 

I turned my key in the lock. It stuck a bit and I panicked as I jiggled the key and retried it. Finally the lock clicked and I pushed open the door, relief flooding through me. 

My relief was short lived, however. It evaporated when I saw what was waiting for me inside. Or rather, what was not waiting for me.

Nothing

There was nothing at all inside. Every scrap of furniture was gone. Every last one of my possessions, gone. All that remained were the indentations in the carpet where my couch and chairs and other furniture had once been.

I was exposed. Bare. Naked. Nothing was left of me. At least nothing of the me that I once was.

My life was being dismantled before my very eyes.

It was time to fight back.

———————————-

Want to know how we got to this point? Check out the other chapters of Impact:

Chapter One

Chapter Two

Chapter Three

Chapter Four

Chapter Five

Chapter Six

Shooting Stars

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“The per patient expenditure for your assigned patient panel the last quarter was up by $XYZ, so we will be dropping your rating on our website from five to four stars. Your patient satisfaction and preventive care scores remain outstanding. We will re-evaluate your rating at next quarter.” A letter from one of the big insurance companies a few weeks ago.

You know what? Bite me. To my knowledge I am not wasting money. I take appropriate care of my patients.

But then it occurred to me, do patients even know that this is what those stars mean? How much money they and their physician cost the insurance company….

The Lost Dollars

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So there is this thing in the US that you may not have heard about. ACO’s, Accountable Care Organizations, are groups of physicians that have “joined together to provide high quality care” for Medicare patients. So says the CMS (Medicare) website.

What does this mean for patients?

Hell if I know. I don’t practice medicine any differently than I always have except that I find myself spending more and more of my time clicking the requisite buttons in the EHR (electronic health record) so patients get less of me. Quality care is quality care and should be given across the board to all patients no matter what bonus structure happens to be in place. I do have suits that come out and flash PowerPoint slides at me that tell how many of my patients ended up in the ER over the past quarter but I don’t pay attention. Frankly, I should not be making a decision whether or not a patient needs to go the ER based on what my “numbers” may or may not look like. 

What does that mean for physicians?

Supposedly, I get money every year that I can demonstrate that I provided savings to Medicare. If Medicare does not spend as much money but patients still get their colonoscopies and whatever else done (I have no idea how that is supposed to work), then I get a share of the “savings.”

How big is that check?

It is not like winning the lottery, that is for sure. I resent the insinuation that I need to be paid extra to do the right thing, but that is beside the point.

The healthcare corporation I work for requires me to complete some…. tasks… before I get this check.

For instance, I have to attend quarterly regional meetings and log onto two separate websites each and every month. To be honest, none of the physicians I know look at anything on those websites. They log on and log off to get the credit. (Of note, I have asked why it has to be two websites. Why can’t it just be one? No one gives me an answer.)

All of this, if it actually improved patient care, would be fine. But it doesn’t. Not one bit. It turns physicians into cute puppies doing silly tricks for their next treat and I refuse to participate. 

By not participating, however, the corporation gets to keep that check. I might not care about that if I knew it was going to go to helping indigent patients get access to care or some other noble cause but I don’t have the foggiest idea what they plan to do with it…

Personally, I think it should go back to Medicare.

A Life of Leisure

Chicago skyscrapers at night

“Doc, when was the last time you went on a mission trip?” He fixed me in his intense gaze. A few minutes before he had told me all about ending up in Rwanda right after the genocide, assisting with Ebola, and secret missions into Syria.

I looked down at my computer, pretending to type. In truth, I was just trying to avoid eye contact as I thought about his question.

“That would have been Cambodia in…. 2007.”

2007.

Had it really been that long?!???!??! 

I felt guilty.

“I’ve been avoiding anything too terribly dangerous while my kiddos were little. Now that they are bigger, I guess I could start thinking about it again.”

He nodded.

“I’ll send you some information…”

Judy Martin at Edwina’s Episodes asked what I would do if I did not have to work. You have all heard about the dream job that will never happen but if I did not need to maintain an income, I would volunteer as a medical aid worker, traveling wherever I was needed.

While I don’t see being able to do that in the foreseeable future, I can do some short stints, a week or two a year, right? 

Here I am in my forties and I still have these romantic notions about saving the world. Truthfully, though, I am not sure I am brave enough to do anything about it. I kinda like my life right now. I can talk a big talk but the follow through? 

Time will tell.

Doubling Over

IMG_5232

“Good news! We got the results of your coding audit and you missed only three things. Please add a 99214 with a modifier to these three office visits so we can post the charges.” The email went on to list the names and dates of service that I was to address.

I go through this every audit. They always find something to nitpick about every year. One year they tell me to do X. I start doing X. Then the next year they tell me I should never do X, I should be only doing Y. Y was what I had been doing before X. And so on….

I don’t like being wrong. I don’t like making mistakes. I don’t like being told what to do, especially if it is something they are going to change on me next year.

Feeling defensive, I looked back at the visits in question this time.

Seriously?

“No way in hell am I going to add those charges. If coding wants to talk to me about it, I am happy to have a discussion with them but I will not be making these changes to the superbill.”

The office visits in question were yearly physicals. Yearly physicals are considered preventive care by insurance companies and as such, the office visit and routine screening labs are covered at 100% by the insurance company. It is not applied to a deductible. There is no copay, no out of pocket expense. 

A “free” visit.

What the coding people wanted me to do was tack on a routine office visit charge in addition to the physical exam visit charge because I addressed something new, like back pain, or made changes to meds for one of their chronic medical problems, like increasing their blood pressure medication.

The problem with this is that particular charge is not a preventive service. It will go to the patient’s deductible. They will get a bill for another $120-140 (or whatever the contracted rate is for their plan) and for most insurances, that means the patient will be paying that entirely themselves out of pocket until their deductible is met. Meanwhile, I get paid for two office visits in the time slotted for the one.

I have been practicing medicine for over ten years. I have known for a long time that it was within my rights to do this but I rarely chose to except for a handful of times in the most extenuating of circumstances.

Just because we can do something does not mean we should do it.

When I have patients skipping specialist referrals and imaging and labs and meds that they really need because of the increasing costs, it bothers me. I need to make money. I do. I have to be able to purchase supplies, pay my staff, and pay the office rent. I need transportation. My kids need clothes, food, and a roof over their heads. The kids will need to go to college and I will need to retire eventually. I make more than enough for this right now, though. I don’t have to double dip. 

The thing that puzzles me at this point is why is coding making it an issue now, this year? It isn’t anything new. There is a lot of paranoia in the medical world about what the future holds for physicians financially, especially with all of the crappy changes to Medicare reimbursement, and that may be part of the reason corporate is starting to pressure us further to maximize our bottom line. I do have to make money for them to make money, after all.

And then I start to wonder. Is there something they know that I don’t?

Should I be grabbing everything I can now and retire early… get out of this business entirely before it collapses so I can go do volunteer work somewhere I am really needed?

In the Nick of Time

interior, Shed Aquarium in Chicago

It was a lovely spring morning. We were outside on the back porch coloring in a circus themed coloring book. Road construction was going a few streets over and a loud thumping repeated, shaking the ground as the workers broke up the concrete.

“Do you hear the elephants?” I asked.

My toddler son nodded, his eyes going wide.

“I think they are coming here! Let’s get some peanuts to feed them!”

He nodded his blonde head vigorously, grinning from ear to ear.

I ran inside and grabbed a bowl, pouring some peanuts into it. 

Then I saw the cashews. 

I’ll throw some in for fun!

I ran back outside and showed him the bowl of nuts. He grabbed a handful, as did I, and put a single cashew into his mouth. He chewed it, still smiling, and then swallowed.

Within seconds, his face turned ashen and his eyes were vacant. He stared off into nothing and would not respond to me at all. He was breathing was labored. His pulse was thready.

Then the hives appeared all over his body and he started to puke.

My son was having an anaphylactic reaction to cashews. 

He survived.

After that, I purchased an epipen and kept it on hand, just in case. 

He has had subsequent severe reactions to pistachios and kiwis. 

I say all of this to say that when I paid for the epipen the first time, it was $150 for a pair of them. Each year, I buy a new epipen to replace the expired one. Each year, the price goes up. Each year, I never have to use it I am throwing away hundreds of dollars. I hate that. Still. It’s my kid we’re talking about here. What kind of parent complains about spending money to protect their kid, right?

The other day I had a patient tell me that they just could not afford the cost of the epipen for their own son. With their high deductible plan they would be paying over $600 for a medication that they would hopefully never have to use. The price increase didn’t really matter so much to patients until the high deductible plans started to become the norm. The price difference before was picked up by insurance companies. Now, it is the patients getting stuck with it.

Yesterday, I ran across this article from the Washington Post about the soaring cost of epipens. Epipens have been around since 2004 but the cost has increased over 450%.

One quote in particular stood out to me:

Mylan (the manufacturer) itself is tight-lipped about the cost increase, saying only that it “has changed over time to better reflect the multiple, important product features and the value the product provides.”

So just how much are you willing to pay for your child’s life? For any child’s life? For a grown up’s life? Because that is what “value” is referring to here. They are holding my son’s life, your child’s life, for ransom. As for important product features…. it injects epinephrine. With a needle. 

Meanwhile, Heather Bresch, the Mylan CEO who has been with the company through the epipen price hikes, has had a substantial pay increase. Her salary in 2007 was  $2,453,456. Last year it was $18,931,068. Which makes me ask the question, how much money does she need?

Dearlilyjune asked what I thought was the greatest health crisis of our time. This is it. The sky rocketing cost of medical care. Pharmaceuticals. Imaging. Hospitalizations. Charging exorbitant amounts just because they can. There is nowhere quite like healthcare where they have you by the balls. Want to live? Want to have a good quality of life? Great! Pay some fat cat through the nose.

It is the worst in the US right now, but I figure it will be only a matter of time before this sort of thing catches on elsewhere. You cannot argue that the strategy makes money. It’s legal, even if it is unethical. 

Greed is powerful.

Lighten Up

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As I write this, I am getting myself and my kids ready to leave the house. My right eye has been twitching and it is hard to breath through the elephant sitting on my chest. 

I was out late last night at a system meeting downtown and I am so exhausted that I decided against running when the alarm went off at 4:30AM. Instead, I lay in bed unable to shut my mind off about not running and about what the day was going to look like at the clinic. 

Yesterday one of the medical assistants (the staff that room patients, give shots, assist with procedures, call messages back to patients) stormed off and left work in the morning because the office manager told her she should not be verbally abusive to other staff, an ongoing issue with her. Will she be back today? 

Dunno. 

That leaves us with three medical assistants for four providers. Admittedly we have had it worse last year (one MA for three providers at times) but it is terribly stressful for the remaining staff. It typically takes 6-8 weeks to find a replacement and get them through HR and the system wide mandated training and into our clinic. During that time the remaining staff get pushed to the max and their job satisfaction starts to crumble. Then it is a snowball effect. One by one they start going elsewhere. You have heard me mention these woes before. It just never seems to stop…

As of last week the clinic is about $48,000 in the hole. Not because we are not seeing patients. It is because we are so far behind on posting charges due to a front desk staff member going out on leave due to mental health issues for six weeks. All of the other front desk personnel had to cover for her which left charge posting on the back burner. Hopefully it will get caught up soon.

This is exhausting. 

Fortunately, I get to introduce my kids to Waffle House tonight. I think waffles will make everything better. 

Temporarily. 

Measured

Cambodia 483

For many years I have been measured on the quality of care I provide. For instance:

Diabetes: Patients had to have a HgA1C (a way of estimating average blood sugar for the prior 3 month period) of under 7.

Blood pressure: The current guideline is under 140/90 for those under 60 years of age and under 150/90 for those over 60. For diabetics it needs to be under 140/90.

There are many more…

The kicker was that if I sent a diabetic to an endocrinologist it does not exempt me from the measures for that patient. In fact, the endocrinologist guideline for control in our system was set for a HgA1C of under 8 and yet I was still measured for quality on that same patient for A1C under 7. If that patient’s A1C was 7.8 the endocrinologist got credit for quality care and I did not.

Blood pressure is even more interesting. Let’s say you have great blood pressures at home but like many people, at the doctor’s office your blood pressure shoots up. I can disgnate a “decision point blood pressure” using your home blood pressure average that keeps us both from getting into trouble. 

BUT let’s say you also see a surgeon or a cardiologist in the system. Your blood pressure is recorded as elevated and they do not use the decision point blood pressure option because they are NOT graded by the system based on these quality measures. Not even the cardiologists.

Meanwhile, I do not get graded only on the blood pressures that I record during office visits with me. No. I get graded by the LAST blood pressure recorded on the chart, regardless of the provider. 

Sooooooo….. 

Even if I am doing everything right, I can still take a hit.

All of the dozens of measures affect how much I get paid. They also affect how much an insurance company requires a patient to shell out as their copay to see a particular physician as a way of directing patients to doctors that provide “quality” for less $.

It is inappropriate for an orthopedic surgeon to be responsible for a patient’s blood pressure but a cardiologist should be held to the same standard as the primary care physician. A dermatologist should not have to worry about whether or not a patient received their flu vaccination but the lung specialist and the endocrinologist should.

Furthermore, if I send a patient to a specialist for management of an particular issue, like diabetes or heart failure, the responsibility for the quality of care for those issues should them be assumed exclusively by that specialist. This discordance in standards unfairly penalizes primary care physicians.

It gets complicated, though, doesn’t it? Who is responsible for what and to what standard?

And that is my two cents worth on a Monday morning! 🙂