Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 Tim et alI got my "1/3" of the healthcare dollar (going to insurance) directly from the mouths of two healthcare researchers who wrote a book in 2007 and who were interviewed on Diane Rehm's NPR show last winter. They also made it very clear, after exhaustive research, that private insurance company administrative costs are 30-35% of their total costs andMedicare administrative costs are around 4%. I remember thefigures well, however, I can't remember the researchers' names. I will get back to the listserve with their names and their book titlewhen I get a moment to look them up.Their figures certainly left an impression on me but it makes sense.If we want any info about Medicare we have to go to their website. They never mail us anything glossy. Their eobs are cut and dried. When I call Medicare I reach a person who gets to the point immediately instead of fighting my way through layers of people which happens with United Healthcare, Aetna, etc., and which is designed to make it difficult. A woman I know who once worked for BCBS of Missouri told methat they were directly told to return a certain percentage of claimsas "need more info" whether they needed it or not, as a stalling tactic.As far as I'm concerned, the private health insurance industry needs to be gone but since that isn't likely to happen, at the very least, it needs to be cleaned up.a OK. I'm sorry for not knowing the exact numbers. I hope, perhaps, someone from the academic areas has the info. But, what percentage of all health care costs are paid out for primary care medicine (pay to docs and charges for what they order)? Then, I wonder, what percentage of insurance premium payments go to insurance company overhead?I am willing to bet that cutting down on insurance company overhead by 1/5-1/3 would be a much, much better savings than cutting down on "inappropriate" medical services (tests ordered, etc) by primary care.If the insurance companies wanted to save money, they'd help primary care thrive so the docs aren't harried and can actually focus on medical care. That, I believe, would cut down on referrals to specialists who charge more per appt and really do order many more tests (very often very appropriately... this is not a rant against specialists who I admire and appreciate a lot). Primary care that is properly comprehensive and then makes the most reasonable and well-timed referrals is the most cost-effective method. A payment system that supports docs to do that is the best answer for American health care.Ask your friend those questions and see what he says?TimChad,Rian's viewpoint is that he will derive his knowledge of evidence-based carefrom reading his medical journals and from attending academic sponsoredCME seminars. For insurance companies to waste precious dollars with wholedepartments devoted to creating practice guidelines for physicians and wholedepartments that create the tri-color brochures and mailings to physicians withthese guidelines is a giant waste of precious health care dollars. Rian said hedoesn't know a single physician, if given the choice, who would pick up theguidelines written by BCBS to read if he can pick up his latest family practicejournal to read guidelines, instead. He finds it insulting that insurancecompanies feel the need to tell physicians how to manage diabetes, for example.As if physicians aren't already seeking the best advice they can get! If they are not,they surely need to seek it directly from the profession and not from insurancecompanies. Imagine the dollars that could be saved in healthcare if all theinsurance companies stopped this wasteful advising practice. When we get that kindof "junk mail", it immediately goes in the trash.The elephant in the middle of the healthcare room (between the provider on one endand the patient on the other) not only siphons off 1/3 of the dollar that goes fromone end of the room to the other, the elephant tells the doctor/hospital/homecareagency how to do their work. It's absurd.a Moffice managerAs we spend a good bit of energy (myself certainly included) highlighting the way insurance companies mistreat primary care, I thought it only fair to relay this story in the interest of balance...I was talking with a friend of mine who works for a large insurance company. He told me that they could pay for every experimental protocol for end-stage cancer request they receive each year in the U.S. if they could only getprimary care docs in Wichita (or any other city of similar size) to stop ordering non-indicated screening labs (lfts, cbcs, basic lytes, etc) and CXRs on asymptomatic patients. He said specifically "we love primary care when it's done right because it saves us a ton of money - the problem is our experience is that most primary care docs don't practice EBM - and for us that's a real hurdle to the logic ofincreasing what we pay them." Food for thought...Chad---------------------------------------- Malia, MDMalia Family Medicine & Skin Sense Laser6720 Pittsford-Palmyra Rd.Perinton Square MallFairport, NY 14450 (phone / fax)www.relayhealth.com/doc/DrMaliawww.SkinSenseLaser.com-- Confidentiality Notice --This email message, including all the attachments, is for the sole use of the intended recipient(s) and contains confidential information. 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Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 And this is exactly where P4P comes into play. The docs who are following the “rules” get compensated a little extra because we’re not ordering unnecessary tests. Pratt Office Manager Oak Tree Internal Medicine P.C Roy Medical Associates, Inc. From: [mailto: ] On Behalf Of chadcostley Sent: Wednesday, December 17, 2008 7:11 AM To: Subject: Evidence-based Care As we spend a good bit of energy (myself certainly included) highlighting the way insurance companies mistreat primary care, I thought it only fair to relay this story in the interest of balance... I was talking with a friend of mine who works for a large insurance company. He told me that they could pay for every experimental protocol for end-stage cancer request they receive each year in the U.S. if they could only get primary care docs in Wichita (or any other city of similar size) to stop ordering non-indicated screening labs (lfts, cbcs, basic lytes, etc) and CXRs on asymptomatic patients. He said specifically " we love primary care when it's done right because it saves us a ton of money - the problem is our experience is that most primary care docs don't practice EBM - and for us that's a real hurdle to the logic of increasing what we pay them. " Food for thought... Chad Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 I didn't take his point to be assigning blame - and he's neither rich nor well-rested. He simply pointed out that doctors have enormous power over healthcare expenditures through our power of prescribing, ordering and referring and that our track record for controlling costs isn't very good. It's a fair point. $11 for an unnecessary cbc (I'll ignore the cost of screening lfts, basic met profiles, sed rates for anyone with a joint ache, urinalysis for sports physicals, " annual complete physicals " for about everyone, annual paps for low-risk patients, baseline EKGs and numerous other primary care habits not based in any evidence) - times tens of millions of clinical visits is real money - billions of dollars. His math isn't nuts. I completely agree that we need a system that supports the right work, but we shouldn't pretend that we (and I mean the collective primary care " we " ) have our own house in order and that everyone else is to blame for this mess. There's plenty of blame to go around. > > > > > > > As we spend a good bit of energy (myself certainly included) > > > > highlighting the way insurance > > > > companies mistreat primary care, I thought it only fair to relay this > > story > > > > in the interest of > > > > balance... > > > > > > > > I was talking with a friend of mine who works for a large insurance > > > > company. He told me > > > > that they could pay for every experimental protocol for end-stage > > cancer > > > > request they > > > > receive each year in the U.S. if they could only get primary care docs > > in > > > > Wichita (or any other > > > > city of similar size) to stop ordering non-indicated screening labs > > (lfts, > > > > cbcs, basic lytes, etc) > > > > and CXRs on asymptomatic patients. He said specifically " we love > > primary > > > > care when it's > > > > done right because it saves us a ton of money - the problem is our > > > > experience is that most > > > > primary care docs don't practice EBM - and for us that's a real hurdle > > to > > > > the logic of > > > > increasing what we pay them. " > > > > > > > > Food for thought... > > > > > > > > Chad > > > > > > > > > > > > > > > > > > > > > > > > -- > > > If you are a patient please allow up to 24 hours for a reply by email/ > > > please note the new email address. > > > Remember that e-mail may not be entirely secure/ > > > MD > > > > > > > > > ph fax > > > > > > > > > > > > > -- > If you are a patient please allow up to 24 hours for a reply by email/ > please note the new email address. > Remember that e-mail may not be entirely secure/ > MD > > > ph fax > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 , Careful about P4P. There have not been any good studies showing the cost effectiveness of this program. In fact, most show no real improvement in quality and slightly increased costs (I think there was one in JAMA earlier this month). We need to enhance the doctor-patient relationship in order to improve care. This is not done by breaking the patient into data points. P4P is another example of the problem we face in the complex world of health care. What sounds initially like a great plan actually leads to increased cost with no real benefit. In my mind it is definitely not the solution. Evidence-based Care As we spend a good bit of energy (myself certainly included) highlighting the way insurance companies mistreat primary care, I thought it only fair to relay this story in the interest of balance... I was talking with a friend of mine who works for a large insurance company. He told me that they could pay for every experimental protocol for end-stage cancer request they receive each year in the U.S. if they could only get primary care docs in Wichita (or any other city of similar size) to stop ordering non-indicated screening labs (lfts, cbcs, basic lytes, etc) and CXRs on asymptomatic patients. He said specifically " we love primary care when it's done right because it saves us a ton of money - the problem is our experience is that most primary care docs don't practice EBM - and for us that's a real hurdle to the logic of increasing what we pay them. " Food for thought... Chad Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 You know I hate change, but I also hate failure. When caught up in the conflict between change or failure, I will choose change—and take immodium. Re: Evidence-based Care So maybe my post wasn't food for thought - perhaps fuel for fire. Your experience in not seeing unnecessary tests and treatments doesn't line-up with national data. The variance and waste in care in this country is dramatic and well- documented - and primary care shares some blame. I dislike them as much as you - I think - but they have data based upon large pools of doctors and patients - we have anecdote. My friend was willing to place a lot of responsibility for the undervaluation of primary care at the doorstep of insurance companies, including his own. My question was whether primary care docs will accept some responsibility also. Always pleased when these kinds of things get discussed with passion:) Chad > > > As we spend a good bit of energy (myself certainly included) > > highlighting the way insurance > > companies mistreat primary care, I thought it only fair to relay this story > > in the interest of > > balance... > > > > I was talking with a friend of mine who works for a large insurance > > company. He told me > > that they could pay for every experimental protocol for end-stage cancer > > request they > > receive each year in the U.S. if they could only get primary care docs in > > Wichita (or any other > > city of similar size) to stop ordering non-indicated screening labs (lfts, > > cbcs, basic lytes, etc) > > and CXRs on asymptomatic patients. He said specifically " we love primary > > care when it's > > done right because it saves us a ton of money - the problem is our > > experience is that most > > primary care docs don't practice EBM - and for us that's a real hurdle to > > the logic of > > increasing what we pay them. " > > > > Food for thought... > > > > Chad > > > > > > > > > > -- > If you are a patient please allow up to 24 hours for a reply by email/ > please note the new email address. > Remember that e-mail may not be entirely secure/ > MD > > > ph fax > -- If you are a patient please allow up to 24 hours for a reply by email/ please note the new email address. Remember that e-mail may not be entirely secure/ MD ph fax Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 another article that provides some food for thought http://www.huffingtonpost.com/maggie-mahar/on-healthcare-reform- stim_b_150572.html Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 and Immodium. I am going to go stock up on A LOT. (I wish I had known this secrete weapon when I started up my IMP...The cost-savings on toilet paper alone would have been staggering!) Also grumpy with a frozen driveway, but not afraid of change..... You know I hate change, but I also hate failure. When caught up in the conflict between change or failure, I will choose change—and take immodium. Re: Evidence-based Care So maybe my post wasn't food for thought - perhaps fuel for fire. Your experience in not seeing unnecessary tests and treatments doesn't line-up with national data. The variance and waste in care in this country is dramatic and well-documented - and primary care shares some blame. I dislike them as much as you - I think - but they have data based upon large pools of doctors and patients - we have anecdote. My friend was willing to place a lot of responsibility for the undervaluation of primary care at the doorstep of insurance companies, including his own. My question was whether primary care docs will accept some responsibility also. Always pleased when these kinds of things get discussed with passion:)Chad > > > As we spend a good bit of energy (myself certainly included)> > highlighting the way insurance> > companies mistreat primary care, I thought it only fair to relay this story> > in the interest of > > balance...> >> > I was talking with a friend of mine who works for a large insurance> > company. He told me> > that they could pay for every experimental protocol for end-stage cancer > > request they> > receive each year in the U.S. if they could only get primary care docs in> > Wichita (or any other> > city of similar size) to stop ordering non-indicated screening labs (lfts, > > cbcs, basic lytes, etc)> > and CXRs on asymptomatic patients. He said specifically " we love primary> > care when it's> > done right because it saves us a ton of money - the problem is our > > experience is that most> > primary care docs don't practice EBM - and for us that's a real hurdle to> > the logic of> > increasing what we pay them. " > >> > Food for thought... > >> > Chad> >> > > >> > > > -- > If you are a patient please allow up to 24 hours for a reply by email/> please note the new email address. > Remember that e-mail may not be entirely secure/> MD> > > ph fax > -- If you are a patient please allow up to 24 hours for a reply by email/please note the new email address. Remember that e-mail may not be entirely secure/ MD ph fax Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 Well,another day at practice improvement 1 non disagreeable disagreeing and ... Imodium! I must say that I think docs have a bit more power than they use- yes- but not t hat much at this point, and I sincerley think and have written in m y local paper ,that docs need to get their own house in order. yes.IMPs are doing exactly that. Often at great sacrifice. The group of people on this list serv is unbelievabley admirable and inspriing to me every d ay.But- I stand my icy ground.BLAMING primary docs for ordering too many screening tests as a reason insurances will not pay for care ( and possibly even unnecessary care) is bas- ackwards. That was the part that caught my eye. The path to cost containtment in teh USA is not through blaming PCPs but at least in part by empowering primary care with good tools and adequate reimbursment and NOT making us have elaborate " work arounds " of " well if they want me to do a prior auth to save them money I as a doc am going to annoy the patitn /stuff my schedule/ and have MAry come in so that I can bill fo r the visit for the PA " the same PA which was suppose to save money but now costs money.LoveJean -- If you are a patient please allow up to 24 hours for a reply by email/please note the new email address.Remember that e-mail may not be entirely secure/ MD ph fax Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 I think we agree more than we disagree on these things. Cheers. > > Well,another day at practice improvement 1 > non disagreeable disagreeing > and ... Imodium! > > I must say that I think docs have a bit more power than they use- yes- > but not t hat much at this point, and > I sincerley think and have written in m y local paper ,that docs need to get > their own house in order. yes. > IMPs are doing exactly that. Often at great sacrifice. The group of people > on this list serv is unbelievabley admirable > and inspriing to me every d ay. > > But- > > I stand my icy ground. > > BLAMING primary docs for ordering too many screening tests as a reason > insurances will not pay for care ( and possibly even unnecessary care) > is bas- ackwards. That was the part that caught my eye. > > The path to cost containtment in teh USA is not through blaming PCPs but at > least in part by empowering primary care with good tools and adequate > reimbursment and NOT making us have elaborate " work arounds " of " well if > they want me to do a prior auth to save them money I as a doc am going > to annoy the patitn /stuff my schedule/ and have MAry come in so that > I can bill fo r the visit for the PA " the same PA which was suppose > to save money but now costs money. > > Love > Jean > > > > > > > > > > > > > > > > > -- > If you are a patient please allow up to 24 hours for a reply by email/ > please note the new email address. > Remember that e-mail may not be entirely secure/ > MD > > > ph fax > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 17, 2008 Report Share Posted December 17, 2008 Yes, we ALL can do " better " in health care when it comes to cost savings, and even quality.And, yes, human nature will make us all see ourselves as better than others (see Brady's report about AAA survey and how folks rate themselves as better than others).But I still contend that a sweeping statement that primary care docs are ordering so many inappropriate tests that if they didn't the insurance industry could pay for expensive new cancer treatments is way, way, off-base, and perhaps delusional ;-).If the statement is that if ALL DOCS stopped ordering inappropriately, or excessively, I might believe the statement. But that would include all the hospital care and the huge number of repetitive labs, studies, etc. Often those are likely to be useless and unnecessary (though often well-intentioned since patient is sick enough to be in hospital and folks " don't want to miss a zebra " ), and boy are those tests expensive!I believe the relative cost of some extra TSH, chem panels, cbc, xrays, etc, by primary care docs does not compare to the huge cost of excessive/inefficient care for the very ill. And, as I said earlier, I also suspect that if insurance companies cut their own overhead by 1/5-1/3 it would save even more money. Others have posted data that might support that belief.Feel free to pass these thoughts to your friend (maybe skip the potential delusions part ;-), and see what he says. I for one, and I suspect others on the list, would love to know his thoughts. Did he really mean primary care docs are that cost-inefficient, or was he referring to all docs and all medical care? Does he have actual data from a good source (not insur industry lobby group or other such entity) that supports the thought? I'd love to learn if we really are that bad and need to make such huge improvements. But first, I'd need to see the data.Tim > On Wed, December 17, 2008 2:40 pm EST, chadcostley wrote:> > > I didn't take his point to be assigning blame - and he's neither rich nor> well-rested. He> simply pointed out that doctors have enormous power over healthcare expenditures> through our power of prescribing, ordering and referring and that our track record> for> controlling costs isn't very good. It's a fair point. $11 for an unnecessary cbc> (I'll ignore> the cost of screening lfts, basic met profiles, sed rates for anyone with a joint> ache,> urinalysis for sports physicals, " annual complete physicals " for about everyone,> annual> paps for low-risk patients, baseline EKGs and numerous other primary care habits not> based in any evidence) - times tens of millions of clinical visits is real money -> billions of> dollars. His math isn't nuts.> > I completely agree that we need a system that supports the right work, but we> shouldn't> pretend that we (and I mean the collective primary care " we " ) have our own house in> order> and that everyone else is to blame for this mess. There's plenty of blame to go> around.> > > > > >> > > > > As we spend a good bit of energy (myself certainly included)> > > > > highlighting the way insurance> > > > > companies mistreat primary care, I thought it only fair to relay this> > > story> > > > > in the interest of> > > > > balance...> > > > >> > > > > I was talking with a friend of mine who works for a large insurance> > > > > company. He told me> > > > > that they could pay for every experimental protocol for end-stage> > > cancer> > > > > request they> > > > > receive each year in the U.S. if they could only get primary care docs> > > in> > > > > Wichita (or any other> > > > > city of similar size) to stop ordering non-indicated screening labs> > > (lfts,> > > > > cbcs, basic lytes, etc)> > > > > and CXRs on asymptomatic patients. He said specifically " we love> > > primary> > > > > care when it's> > > > > done right because it saves us a ton of money - the problem is our> > > > > experience is that most> > > > > primary care docs don't practice EBM - and for us that's a real hurdle> > > to> > > > > the logic of> > > > > increasing what we pay them. " > > > > >> > > > > Food for thought...> > > > >> > > > > Chad> > > > >> > > > >> > > > >> > > >> > > >> > > >> > > > --> > > > If you are a patient please allow up to 24 hours for a reply by email/> > > > please note the new email address.> > > > Remember that e-mail may not be entirely secure/> > > > Jean Antonucci MD> > > > > > > > > > > > ph fax > > > >> > >> > >> > >> >> >> >> > --> > If you are a patient please allow up to 24 hours for a reply by email/> > please note the new email address.> > Remember that e-mail may not be entirely secure/> > MD> > 115 Mt Blue Circle> > > > ph fax > >> > > > > ------------------------------------> > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 18, 2008 Report Share Posted December 18, 2008 I agree we probably order some unnecessary tests. There are many reasons. One, CYA. Two, the patient expects it. Three, sometimes it’s just quicker to order blood work, pronounce patient healthy, which we already knew and send them home reassured rather than spend 15 minutes on how you are quite sure they are healthy and you find nothing wrong. Patients believe in technology. Four, already done by someone else but have been trying to get old records for weeks, months and give up. Five, if you send them to specialist they want MRI first before seeing them. Six, Men’s magazine and Health magazines tell patients they should be getting these tests and after all, they are more believable then us. Seven, doctor too busy and too tired and tests buy time for patient to get better anyway. Eight, tests pay better and doctor needs some income. Nine, I live in NJ and everyone wants a Lyme test as they all know someone who died or is in a wheelchair from Lyme. Ten, first tests you ordered are normal, patient not reassured and now you have to keep looking (abdominal pain good example). This turned into a “top 10” so I had to stretch a little but you all get the gist. However, to say that this adds up to more than experimental cancer treatments is, I believe, ridiculous. Even non-experimental cancer treatments are outrageously expensive. One month of cancer treatment could probably provide 1 years healthcare for 100 people. Kathy Saradarian, MD Branchville, NJ www.qualityfamilypractice.com Solo 4/03, Practicing since 9/90 Practice Partner 5/03 Low staffing From: [mailto: ] On Behalf Of chadcostley Sent: Wednesday, December 17, 2008 2:40 PM To: Subject: Re: Evidence-based Care I didn't take his point to be assigning blame - and he's neither rich nor well-rested. He simply pointed out that doctors have enormous power over healthcare expenditures through our power of prescribing, ordering and referring and that our track record for controlling costs isn't very good. It's a fair point. $11 for an unnecessary cbc (I'll ignore the cost of screening lfts, basic met profiles, sed rates for anyone with a joint ache, urinalysis for sports physicals, " annual complete physicals " for about everyone, annual paps for low-risk patients, baseline EKGs and numerous other primary care habits not based in any evidence) - times tens of millions of clinical visits is real money - billions of dollars. His math isn't nuts. I completely agree that we need a system that supports the right work, but we shouldn't pretend that we (and I mean the collective primary care " we " ) have our own house in order and that everyone else is to blame for this mess. There's plenty of blame to go around. > > > > > > > As we spend a good bit of energy (myself certainly included) > > > > highlighting the way insurance > > > > companies mistreat primary care, I thought it only fair to relay this > > story > > > > in the interest of > > > > balance... > > > > > > > > I was talking with a friend of mine who works for a large insurance > > > > company. He told me > > > > that they could pay for every experimental protocol for end-stage > > cancer > > > > request they > > > > receive each year in the U.S. if they could only get primary care docs > > in > > > > Wichita (or any other > > > > city of similar size) to stop ordering non-indicated screening labs > > (lfts, > > > > cbcs, basic lytes, etc) > > > > and CXRs on asymptomatic patients. He said specifically " we love > > primary > > > > care when it's > > > > done right because it saves us a ton of money - the problem is our > > > > experience is that most > > > > primary care docs don't practice EBM - and for us that's a real hurdle > > to > > > > the logic of > > > > increasing what we pay them. " > > > > > > > > Food for thought... > > > > > > > > Chad > > > > > > > > > > > > > > > > > > > > > > > > -- > > > If you are a patient please allow up to 24 hours for a reply by email/ > > > please note the new email address. > > > Remember that e-mail may not be entirely secure/ > > > MD > > > > > > > > > ph fax > > > > > > > > > > > > > -- > If you are a patient please allow up to 24 hours for a reply by email/ > please note the new email address. > Remember that e-mail may not be entirely secure/ > MD > > > ph fax > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 18, 2008 Report Share Posted December 18, 2008 Amen, Kathy.As I posted before, insurance companies could save a LOT of money bycompletely getting rid of their departments that research clinical publicationsand then create guidelines that physicians don't read. (not from insurance companies, anyway) Priority Heath (which keeps winning awards!) here in Michigan sends us a large, glossy (expensive to produce) folder every month packed with new guidelines and advice sheets and measurements of clinical parameters. They are our only HMO and we have about 70 patientsin that panel. They mean well but it is an incredible waste of resources andan assumption that busy offices have hours to read this stuff. Are Rian and I the only ones who feel this piece of the insurance industryis wasteful?aI agree we probably order some unnecessary tests. There are many reasons. One, CYA. Two, the patient expects it. Three, sometimes it’s just quicker to order blood work, pronounce patient healthy, which we already knew and send them home reassured rather than spend 15 minutes on how you are quite sure they are healthy and you find nothing wrong. Patients believe in technology. Four, already done by someone else but have been trying to get old records for weeks, months and give up. Five, if you send them to specialist they want MRI first before seeing them. Six, Men’s magazine and Health magazines tell patients they should be getting these tests and after all, they are more believable then us. Seven, doctor too busy and too tired and tests buy time for patient to get better anyway. Eight, tests pay better and doctor needs some income. Nine, I live in NJ and everyone wants a Lyme test as they all know someone who died or is in a wheelchair from Lyme. Ten, first tests you ordered are normal, patient not reassured and now you have to keep looking (abdominal pain good example). This turned into a “top 10” so I had to stretch a little but you all get the gist. However, to say that this adds up to more than experimental cancer treatments is, I believe, ridiculous. Even non-experimental cancer treatments are outrageously expensive. One month of cancer treatment could probably provide 1 years healthcare for 100 people. Kathy Saradarian, MDBranchville, NJwww.qualityfamilypractice.comSolo 4/03, Practicing since 9/90Practice Partner 5/03Low staffing From: [mailto: ] On Behalf Of chadcostleySent: Wednesday, December 17, 2008 2:40 PMTo: Subject: Re: Evidence-based Care I didn't take his point to be assigning blame - and he's neither rich nor well-rested. He simply pointed out that doctors have enormous power over healthcare expenditures through our power of prescribing, ordering and referring and that our track record for controlling costs isn't very good. It's a fair point. $11 for an unnecessary cbc (I'll ignore the cost of screening lfts, basic met profiles, sed rates for anyone with a joint ache,urinalysis for sports physicals, "annual complete physicals" for about everyone, annual paps for low-risk patients, baseline EKGs and numerous other primary care habits not based in any evidence) - times tens of millions of clinical visits is real money - billions of dollars. His math isn't nuts.I completely agree that we need a system that supports the right work, but we shouldn't pretend that we (and I mean the collective primary care "we") have our own house in order and that everyone else is to blame for this mess. There's plenty of blame to go around. > > >> > > > As we spend a good bit of energy (myself certainly included)> > > > highlighting the way insurance> > > > companies mistreat primary care, I thought it only fair to relay this> > story> > > > in the interest of> > > > balance...> > > >> > > > I was talking with a friend of mine who works for a large insurance> > > > company. He told me> > > > that they could pay for every experimental protocol for end-stage> > cancer> > > > request they> > > > receive each year in the U.S. if they could only get primary care docs> > in> > > > Wichita (or any other> > > > city of similar size) to stop ordering non-indicated screening labs> > (lfts,> > > > cbcs, basic lytes, etc)> > > > and CXRs on asymptomatic patients. He said specifically "we love> > primary> > > > care when it's> > > > done right because it saves us a ton of money - the problem is our> > > > experience is that most> > > > primary care docs don't practice EBM - and for us that's a real hurdle> > to> > > > the logic of> > > > increasing what we pay them."> > > >> > > > Food for thought...> > > >> > > > Chad> > > >> > > >> > > >> > >> > >> > >> > > --> > > If you are a patient please allow up to 24 hours for a reply by email/> > > please note the new email address.> > > Remember that e-mail may not be entirely secure/> > > MD> > > > > > > > > ph fax > > >> >> > > >> > > > -- > If you are a patient please allow up to 24 hours for a reply by email/> please note the new email address.> Remember that e-mail may not be entirely secure/> MD> > > ph fax > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 18, 2008 Report Share Posted December 18, 2008 I am curious as to how they determined that the screening cbc or cmp or rpr or hepatitis tests are unnecessary just because a perosn is asymptomatic. We've had asymptomatic chronic hep b patients come in and, since they were apparently told it was nothing to be done or to worry about (yes! they at least told us that they were told this) they didn't mention it. We found out from the blood test. They hadn't even told their sex partner! We've also had cases of syphills. We get elevated liver enzymes quite frequently. And we had one apparently young healthy female who just mentioned in passing that she had fainted while washing clothes in her dorm 3 months prior. Otherwise she felt fine. She later went to an ER where they did an EKG but didnt draw blood. Well we did, and received a call from the lab. She was dangerously anemic. Luckily, we were able to contact her and get her to an ER. Lucky she didn't faint while crossing the street or driving. Amazingly, even though we are in NYC we have yet to have an HIV screening come back positive (I'm now crossing my fingers and knocking on my wooden desk.) To: Sent: Wednesday, December 17, 2008 11:53:56 AMSubject: Re: Evidence-based CareSo maybe my post wasn't food for thought - perhaps fuel for fire. Your experience in not seeing unnecessary tests and treatments doesn't line-up with national data. The variance and waste in care in this country is dramatic and well-documented - and primary care shares some blame. I dislike them as much as you - I think - but they have data based upon large pools of doctors and patients - we have anecdote. My friend was willing to place a lot of responsibility for the undervaluation of primary care at the doorstep of insurance companies, including his own. My question was whether primary care docs will accept some responsibility also. Always pleased when these kinds of things get discussed with passion:)Chad> > > As we spend a good bit of energy (myself certainly included)> > highlighting the way insurance> > companies mistreat primary care, I thought it only fair to relay this story> > in the interest of> > balance...> >> > I was talking with a friend of mine who works for a large insurance> > company. He told me> > that they could pay for every experimental protocol for end-stage cancer> > request they> > receive each year in the U.S. if they could only get primary care docs in> > Wichita (or any other> > city of similar size) to stop ordering non-indicated screening labs (lfts,> > cbcs, basic lytes, etc)> > and CXRs on asymptomatic patients. He said specifically "we love primary> > care when it's> > done right because it saves us a ton of money - the problem is our> > experience is that most> > primary care docs don't practice EBM - and for us that's a real hurdle to> > the logic of> > increasing what we pay them."> >> > Food for thought...> >> > Chad> >> > > >> > > > -- > If you are a patient please allow up to 24 hours for a reply by email/> please note the new email address.> Remember that e-mail may not be entirely secure/> MD> > > ph fax >------------------------------------ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 18, 2008 Report Share Posted December 18, 2008 I completely agree, and told them so. Also hate the chronic disease management reminders on patients, so you pull up the chart, because it says they haven't had their HBA1c or whatever, but they have, the insurance company, just can''t even mine their own data correctly. --------- Re: Evidence-based Care I didn't take his point to be assigning blame - and he's neither rich nor well-rested. He simply pointed out that doctors have enormous power over healthcare expenditures through our power of prescribing, ordering and referring and that our track record for controlling costs isn't very good. It's a fair point. $11 for an unnecessary cbc (I'll ignore the cost of screening lfts, basic met profiles, sed rates for anyone with a joint ache,urinalysis for sports physicals, "annual complete physicals" for about everyone, annual paps for low-risk patients, baseline EKGs and numerous other primary care habits not based in any evidence) - times tens of millions of clinical visits is real mo ney - billions of dollars. His math isn't nuts.I completely agree that we need a system that supports the right work, but we shouldn't pretend that we (and I mean the collective primary care "we") have our own house in order and that everyone else is to blame for this mess. There's plenty of blame to go around. > > >> > > > As we spend a good bit of energy (myself certainly included)> > > > highlighting the way insurance> > > > companies mistreat primary care, I thought it only fair to relay this> > story> > > > in the interest of> > > > balance...> > > >> > > > I was talking with a friend of mine who works for a large insurance> > > > company. He told me> > > > that they could pay for every experimental protocol for end-stage> > cancer> > > > request they> > > > receive each year in the U.S. if they could only get primary care docs> > in> > > > Wichita (or any other> > > > city of similar size) to stop ordering non-indicated screening labs> > (lfts, gt; > > > cbcs, basic lytes, etc)> > > > and CXRs on asymptomatic patients. He said specifically "we love> > primary> > > > care when it's> > > > done right because it saves us a ton of money - the problem is our> > > > experience is that most> > > > primary care docs don't practice EBM - and for us that's a real hurdle> > to> > > > the logic of> > > > increasing what we pay them."> > > >> > > > Food for thought...> > > >> > > > Chad> > > >> > > >> > > >> > >> > >> > >> > > --> > > If you are a patient please allow up to 24 hours for a reply by email/> > > please note the new email address.> > > Remember that e-mail may not be entirely secure/ BR>> > > MD> > > > > > > > > ph fax > > >> >> > > >> > > > -- > If you are a patient please allow up to 24 hours for a reply by email/> please note the new email address.> Remember that e-mail may not be entirely secure/> MD> > > ph fax > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 18, 2008 Report Share Posted December 18, 2008 wayne " screening " would not be most of what you sayscreening here would be drawing blood on someone with no compaints or suggestive history T o investigate fainting or abnl lfts etc looking for hepatitis is not screening The question I think originates for the ordering of labs for what patients still often preceive of as " routine " , done in prior years, whereas now adays there maybe " routine " : lipid screening at cetain ages in c ertian populations- you know begin at age x and if fine do every 5 yrs etc Patients often t hink a physical must involve an ekg urine cbc etc but when there is n oindicationfor them they should n ot be ordered .This takes some e ducation about what is needed at certain ages and why Ordering an ekg on a hypertensive patietn is not screening, it is looking for end organ damage- LVH ;ordering an ekg on say ,me, is screenign -- but for what? Nothing. Orderingfobtr cards on me is also screenign but based on the evidence that there is some disease sufficiently dangerous about which we can make an intervention that is worthwhile to do an inexpensive relatively simplee test for, so as to make an impact -- that paraphrased is what screening is. SO there is no such things as a screening cbc in mostpeople Gerting a cbc in women with heavy periods has a reason behind it see? I am trying to give many examples. screening urines I do not think exist for any circumstance for example. etc doe s that clarify?Excuse me if you knew al l this my sense was that you were asking about screeinng which has a precise definition.Jean I am curious as to how they determined that the screening cbc or cmp or rpr or hepatitis tests are unnecessary just because a perosn is asymptomatic. We've had asymptomatic chronic hep b patients come in and, since they were apparently told it was nothing to be done or to worry about (yes! they at least told us that they were told this) they didn't mention it. We found out from the blood test. They hadn't even told their sex partner! We've also had cases of syphills. We get elevated liver enzymes quite frequently. And we had one apparently young healthy female who just mentioned in passing that she had fainted while washing clothes in her dorm 3 months prior. Otherwise she felt fine. She later went to an ER where they did an EKG but didnt draw blood. Well we did, and received a call from the lab. She was dangerously anemic. Luckily, we were able to contact her and get her to an ER. Lucky she didn't faint while crossing the street or driving. Amazingly, even though we are in NYC we have yet to have an HIV screening come back positive (I'm now crossing my fingers and knocking on my wooden desk.) To: Sent: Wednesday, December 17, 2008 11:53:56 AMSubject: Re: Evidence-based CareSo maybe my post wasn't food for thought - perhaps fuel for fire. Your experience in not seeing unnecessary tests and treatments doesn't line-up with national data. The variance and waste in care in this country is dramatic and well-documented - and primary care shares some blame. I dislike them as much as you - I think - but they have data based upon large pools of doctors and patients - we have anecdote. My friend was willing to place a lot of responsibility for the undervaluation of primary care at the doorstep of insurance companies, including his own. My question was whether primary care docs will accept some responsibility also. Always pleased when these kinds of things get discussed with passion:)Chad > > > As we spend a good bit of energy (myself certainly included)> > highlighting the way insurance> > companies mistreat primary care, I thought it only fair to relay this story> > in the interest of > > balance...> >> > I was talking with a friend of mine who works for a large insurance> > company. He told me> > that they could pay for every experimental protocol for end-stage cancer> > request they> > receive each year in the U.S. if they could only get primary care docs in > > Wichita (or any other> > city of similar size) to stop ordering non-indicated screening labs (lfts,> > cbcs, basic lytes, etc)> > and CXRs on asymptomatic patients. He said specifically " we love primary > > care when it's> > done right because it saves us a ton of money - the problem is our> > experience is that most> > primary care docs don't practice EBM - and for us that's a real hurdle to > > the logic of> > increasing what we pay them. " > >> > Food for thought...> >> > Chad> >> > > >> > > > -- > If you are a patient please allow up to 24 hours for a reply by email/> please note the new email address.> Remember that e-mail may not be entirely secure/> MD> > > ph fax >------------------------------------ Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 18, 2008 Report Share Posted December 18, 2008 We get more notices from HIP of NY saying patients haven't had their A1C, or haven't had their colonoscopy, or whatever, and when we chech the chart they had it 3 months prior. yep, can't even look at their own claims data properly. To: Sent: Thursday, December 18, 2008 3:06:10 PMSubject: Re: Re: Evidence-based Care I completely agree, and told them so. Also hate the chronic disease management reminders on patients, so you pull up the chart, because it says they haven't had their HBA1c or whatever, but they have, the insurance company, just can''t even mine their own data correctly. --------- [Practiceimprovemen t1] Re: Evidence-based Care I didn't take his point to be assigning blame - and he's neither rich nor well-rested. He simply pointed out that doctors have enormous power over healthcare expenditures through our power of prescribing, ordering and referring and that our track record for controlling costs isn't very good. It's a fair point. $11 for an unnecessary cbc (I'll ignore the cost of screening lfts, basic met profiles, sed rates for anyone with a joint ache,urinalysis for sports physicals, "annual complete physicals" for about everyone, annual paps for low-risk patients, baseline EKGs and numerous other primary care habits not based in any evidence) - times tens of millions of clinical visits is real mo ney - billions of dollars. His math isn't nuts.I completely agree that we need a system that supports the right work, but we shouldn't pretend that we (and I mean the collective primary care "we") have our own house in order and that everyone else is to blame for this mess. There's plenty of blame to go around. > > >> > > > As we spend a good bit of energy (myself certainly included)> > > > highlighting the way insurance> > > > companies mistreat primary care, I thought it only fair to relay this> > story> > > > in the interest of> > > > balance...> > > >> > > > I was talking with a friend of mine who works for a large insurance> > > > company. He told me> > > > that they could pay for every experimental protocol for end-stage> > cancer> > > > request they> > > > receive each year in the U.S. if they could only get primary care docs> > in> > > > Wichita (or any other> > > > city of similar size) to stop ordering non-indicated screening labs> > (lfts, & gt; > > > cbcs, basic lytes, etc)> > > > and CXRs on asymptomatic patients. He said specifically "we love> > primary> > > > care when it's> > > > done right because it saves us a ton of money - the problem is our> > > > experience is that most> > > > primary care docs don't practice EBM - and for us that's a real hurdle> > to> > > > the logic of> > > > increasing what we pay them."> > > >> > > > Food for thought...> > > >> > > > Chad> > > >> > > >> > > >> > >> > >> > >> > > --> > > If you are a patient please allow up to 24 hours for a reply by email/> > > please note the new email address.> > > Remember that e-mail may not be entirely secure/< BR>> > > MD> > > > > > > > > ph fax > > >> >> > > >> > > > -- > If you are a patient please allow up to 24 hours for a reply by email/> please note the new email address.> Remember that e-mail may not be entirely secure/> MD> > > ph fax > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 18, 2008 Report Share Posted December 18, 2008 I remember having a rather long rant with the BCBS representative a couple of years ago when they decided to go to prior auths for all CT scans. When I asked why, she stated that radiology procedures were quickly becoming one of the most expensive aspects of medical care and so BCBS felt they needed to make sure that all the tests ordered were appropriate. When I asked the follow-up question of whether I had been found to order too many tests, she stated, “Well, you see there is the problem…we have no way of looking up that information.” So they decided to abuse all physicians because of the actions of a few. Isn’t it interesting that the same insurance companies who cannot track something as expensive as CTs and MRIs through claims data feel they have a good grasp on how many HGBA1Cs a doc orders? If indeed they can accurately track this data, then what is the need for prior auths for the radiologic procedures? Again, we can all do better in terms of cost containment, but I hesitate to listen to a publicly traded for profit organization interested only in the bottom line. Re: Re: Evidence-based Care I completely agree, and told them so. Also hate the chronic disease management reminders on patients, so you pull up the chart, because it says they haven't had their HBA1c or whatever, but they have, the insurance company, just can''t even mine their own data correctly. --------- [Practiceimprovemen t1] Re: Evidence-based Care I didn't take his point to be assigning blame - and he's neither rich nor well-rested. He simply pointed out that doctors have enormous power over healthcare expenditures through our power of prescribing, ordering and referring and that our track record for controlling costs isn't very good. It's a fair point. $11 for an unnecessary cbc (I'll ignore the cost of screening lfts, basic met profiles, sed rates for anyone with a joint ache, urinalysis for sports physicals, " annual complete physicals " for about everyone, annual paps for low-risk patients, baseline EKGs and numerous other primary care habits not based in any evidence) - times tens of millions of clinical visits is real mo ney - billions of dollars. His math isn't nuts. I completely agree that we need a system that supports the right work, but we shouldn't pretend that we (and I mean the collective primary care " we " ) have our own house in order and that everyone else is to blame for this mess. There's plenty of blame to go around. > > > > > > > As we spend a good bit of energy (myself certainly included) > > > > highlighting the way insurance > > > > companies mistreat primary care, I thought it only fair to relay this > > story > > > > in the interest of > > > > balance... > > > > > > > > I was talking with a friend of mine who works for a large insurance > > > > company. He told me > > > > that they could pay for every experimental protocol for end-stage > > cancer > > > > request they > > > > receive each year in the U.S. if they could only get primary care docs > > in > > > > Wichita (or any other > > > > city of similar size) to stop ordering non-indicated screening labs > > (lfts, & gt; > > > cbcs, basic lytes, etc) > > > > and CXRs on asymptomatic patients. He said specifically " we love > > primary > > > > care when it's > > > > done right because it saves us a ton of money - the problem is our > > > > experience is that most > > > > primary care docs don't practice EBM - and for us that's a real hurdle > > to > > > > the logic of > > > > increasing what we pay them. " > > > > > > > > Food for thought... > > > > > > > > Chad > > > > > > > > > > > > > > > > > > > > > > > > -- > > > If you are a patient please allow up to 24 hours for a reply by email/ > > > please note the new email address. > > > Remember that e-mail may not be entirely secure/< BR>> > > MD > > > > > > > > > ph fax > > > > > > > > > > > > > -- > If you are a patient please allow up to 24 hours for a reply by email/ > please note the new email address. > Remember that e-mail may not be entirely secure/ > MD > > > ph fax > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted December 19, 2008 Report Share Posted December 19, 2008 This is a great example of idiocy. I saw a new couple yesterday, they wanted flu vaccine and pertussis vaccine as their daughter’s pediatrician recommended it, she is 5 months. SO I do the complete physical, history, etc. Go over recommending health maintenance; it was a really quiet day so take probably 2-1/2 hours with the 2 of them and playing with the kids a little. Give the shots. All is fine. Husband had mentioned that he had left some paper at home that gave all the recommended health exams for a man his age (41). I advised them what they were, etc. Wife was second and she asked if husband got EKG as this was recommended on a flyer they got from the health insurance company (Horizon BCBS of all plans). I advised that screening EKGs are really never recommended and particularly not on anyone with no risks for heart disease. She promised to fax me the flyer, well I am in shock! I can’t believe they are willing to pay for all for this. They say these recommendations come from the Men’s Health Network. Testicular self-exam Monthly (no ages) Blood Pressure Annually Rectal Exam Annually (again no ages) Physical exam Ages 20-39 q 3 years (yet they need annual rectal exams) Ages 40-49 q 2 years Ages 50 and older - Annually Blood tests and urinalysis Ages 20-39 q 3 years (screening for cholesterol, Ages 40-49 q 2 years DM, kidney or thyroid and Ages 50 and older - Annually other problems) EKG Baseline at age 30 Ages 40-49 q4y Ages 50 and older q3y Testosterone screening Ages 40 and older – discuss with your physician Chest x-ray Annually if a smoker and over age 45 Hemoccult Age 40 and older – Annually PSA Age 50 and older – Annually, earlier for African- Americans and those with a Fam Hx or Prostate CA Colorectal flexible scope Age 50 and older – every 3-4 years Screening TB skin test Every 5 years Tetanus booster Every 10 years Bone mineral density Age 60 and older – discuss with your physician (gee thanks) Sexually transmitted Sexually active adults at risk should talk to their physician Source: Checkup and Screening Guidelines, For Men and Women:Get it Checked! Men’s Health Network, www.menshealthnetwork.org; www. Nwhealth.edu/healthy/UfindBalance/mhealth.html And we do unnecessary testing? From: [mailto: ] On Behalf Of Wayne Coghill Sent: Thursday, December 18, 2008 2:17 PM To: Subject: Re: Re: Evidence-based Care I am curious as to how they determined that the screening cbc or cmp or rpr or hepatitis tests are unnecessary just because a perosn is asymptomatic. We've had asymptomatic chronic hep b patients come in and, since they were apparently told it was nothing to be done or to worry about (yes! they at least told us that they were told this) they didn't mention it. We found out from the blood test. They hadn't even told their sex partner! We've also had cases of syphills. We get elevated liver enzymes quite frequently. And we had one apparently young healthy female who just mentioned in passing that she had fainted while washing clothes in her dorm 3 months prior. Otherwise she felt fine. She later went to an ER where they did an EKG but didnt draw blood. Well we did, and received a call from the lab. She was dangerously anemic. Luckily, we were able to contact her and get her to an ER. Lucky she didn't faint while crossing the street or driving. Amazingly, even though we are in NYC we have yet to have an HIV screening come back positive (I'm now crossing my fingers and knocking on my wooden desk.) To: Sent: Wednesday, December 17, 2008 11:53:56 AM Subject: Re: Evidence-based Care So maybe my post wasn't food for thought - perhaps fuel for fire. Your experience in not seeing unnecessary tests and treatments doesn't line-up with national data. The variance and waste in care in this country is dramatic and well- documented - and primary care shares some blame. I dislike them as much as you - I think - but they have data based upon large pools of doctors and patients - we have anecdote. My friend was willing to place a lot of responsibility for the undervaluation of primary care at the doorstep of insurance companies, including his own. My question was whether primary care docs will accept some responsibility also. Always pleased when these kinds of things get discussed with passion:) Chad > > > As we spend a good bit of energy (myself certainly included) > > highlighting the way insurance > > companies mistreat primary care, I thought it only fair to relay this story > > in the interest of > > balance... > > > > I was talking with a friend of mine who works for a large insurance > > company. He told me > > that they could pay for every experimental protocol for end-stage cancer > > request they > > receive each year in the U.S. if they could only get primary care docs in > > Wichita (or any other > > city of similar size) to stop ordering non-indicated screening labs (lfts, > > cbcs, basic lytes, etc) > > and CXRs on asymptomatic patients. He said specifically " we love primary > > care when it's > > done right because it saves us a ton of money - the problem is our > > experience is that most > > primary care docs don't practice EBM - and for us that's a real hurdle to > > the logic of > > increasing what we pay them. " > > > > Food for thought... > > > > Chad > > > > > > > > > > -- > If you are a patient please allow up to 24 hours for a reply by email/ > please note the new email address. > Remember that e-mail may not be entirely secure/ > MD > > > ph fax > ------------------------------------ Quote Link to comment Share on other sites More sharing options...
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