A Challenge

by admin on 06/19/2011 1:39 PM

This year we were obligated to take on 250 ObamaCare patients. These were patients without insurance, on welfare, on Medicaid who were given HMO insurance. This was a more massive change in our practice than I could have anticipated in my wildest imagination. I had to promise my front office this was an obligation to the poor and disenfranchise to provide this care. We’ve always had 20 percent of our patients on Medicaid as our obligation. But this 20% had meshed with our private practice and handled themselves much like private patients. They made appointments, follow our recommendations, kept their return appointments, and presented themselves in a manner that didn’t disturb our private patients.

The first day when those 250 ObamaCare/Welfare/Medicaid patients were place in out HMO panel, we had rude awakening. My front desk was managed by my wife, Linda for the past decade or so. Normally when she arrived at my reception front desk, she would have three or four messages on the phone.  She would respond to these and then get on with her work.

She arrived at the usual time, and found 65 messages on the phone. It took her two hours to record these and another three hours to respond to them. We thought this was just the preliminary response from patients who may have been waiting to obtain care. However, this continued on a daily basis. This extra five hours of work on a daily basis would add up to and extra 25 hours per week or 100 hours per month. The going rate in our community is $30 per hour. One hundred hours at $30 per hour is an extra $3,000 per month of medical costs.

These calls didn’t come in during normal business hours but all hours of day and night. We quickly realized that these patients were not employed and hence were up at all hours of day and night. They all had cell phones and would call and leave lengthy messages at midnight or three o’clock in the morning.

They were also very demanding, many insisting on being seen immediately. If we didn’t fit them in soon enough, they would call our HMO who assured them it was their policy that appointments were to be made in 24 to 48 hours. Then we received letters of reprimand for not providing prompt service. These complaints would then go to the state HMO program who would demand an explanation to be routed through our HMO.  We would then respond to our HMO and maybe it would then be dropped. However, some were appealed. Appeals through a state bureaucracy could be very time consuming with a serious loss of income. The harassment was a much larger emotional cost.

The operation of our reception area was devastated. Along with the changes in ObamaCare, Medicare and Medicaid placed numerous restrictions on care.  For forty years, I could write a prescription, or order a test or x—ray and the reception area would route the patient to the appropriate facility. This along with the billing and making further appointments fell in the range of 5 minutes of work.

This past month new Medicare restrictions implemented through our HMO required changes in the medications that the patient may have been on for a decade or two. They were upset that they were unable to get the medications they were used to obtaining.  The pharmacy would tell them “just have your doctor do a prior authorization” simply known as a PA. We did several of these and they took hours to finally obtain a medication that Medicare through our HMO covered. This could take hours of my office manager’s time over several days to process something that was covered. Medicare always demanded a listing of all the drugs that had been tried. Since, the trial process may have occurred a decade or two previously by another physician, this became an indeterminable process. My prescription writing time of a minute or two became 10 or 15 minutes after several rewrites.

As a pulmonologist who had treated respiratory failure for more than 40 years, this became a nightmare. For 40 years, after measuring the oxygen saturation, I would complete an oxygen prescription form, and my receptionist would fax this to the oxygen company. The oxygen would normal arrive at the patient’s home by the time they were home from my office. The first oxygen requisition I wrote after the new regulation, took several lengthy phone calls to the oxygen company. They range that must be written on the new Medicare forms. They required the low oxygen (hypoxia) documentation. After several phone calls, we fax the entire three page office visit documenting the low oxygen which we underline with heavy black ink that would transmit via fax. After hours, the lady at the oxygen company said the oxygen was in my own hand writing, not a printout from a machine. Most of us don’t have the multi-thousand dollar fancy hospital equipment and have always use the standard pulse oximeter that clamps on the finger. My first one cost me $350. The large Blood pressure, pulse, oxygen apparatus costs about $3500 and is no more accurate. I finally gave up on further phone calls. The first patient whose arterial oxygen was down to 78% from the normal of 98%,  (blue venous blood is 75%) was so short of breath I had to help her to the car. She declined to be hospitalized. She had to spend two months gasping for each breath before the oxygen could be approved. From a usual two hour wait to a two month wait. These types of costs, monetary (staff), time (hours to days to weeks etc.), patient increased risks (including dying in organ failure), increased suffering (shortness of breath – gasping for two month) never show up on a government or Medicare cost analysis even though they were doubled or tripled or quadrupled). Doctors or staff time is never measured. The pharmacists have similar increase in costs. Hospitals just hire more accountants, bookkeepers, insurance billers, Medicare, Medicaid experts and can usually recover costs including their significant increase because of government regulations.

(N.B. we once researched the reimbursement of our seeing a patient in lung failure on two tanks of oxygen in her home and the hospital reimbursement for a similar visit by their nurse or therapist. The hospital was able to charge more than 10 times what we were able to charge for the same work. Only we were the ones that were able to make the assessment and write orders that the hospital therapist would follow on his home visit. Normally they would call us to give them the oxygen and treatment orders which Medicare considers an irrelevant cost.)

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The Future of Health Care Has to Be Lean, Efficient and Personal.
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