xtcian

Good morning, everyone.

I would like to make sweet, sweet love to all of you.

Seriously, I'm a day late here, but anyone have good stories of successful April Fools pranks?

Or maybe in these times, we should go back to arguing about Obama vs. Hillary. Although it can't possibly go on for much longer.

Hey do you still want to go to San Antonio? Call me?

Chip

Who do you think the Democratic elders will lean on more to quit? Hillary or Obama?

More to the point, will anyone step up and suggest that the Super Delegates vote NOW rather than waiting? I saw that they might do that in July, but that's three more months of pummeling while the Republicans sit and wait.

yeah, who all will be in San Antonio for the Final 4? I have my tickets and will be driving down Friday night?

Sorry Ian for taking over your comments here and I hope someone will bite at this but..
I have a question for the group because I think you're a smart bunch and I need advice to help me form ideas for the future.
What do you want in a doctor? If your doctor would provide that would you consider paying cash (either pay cash up front and possibly file your own insurance like at the dentist or simply pay cash in total if it were a reasonable amount).
I am struggling with the large production based model of primary care and all the billing and overhead costs that requires. There are several new models around that involve much lower overhead practices with few if any employees, higher levels of service and better physician availability (which is how I practice any way) but little to no insurance billing which would actual allow cash discounts and lower costs to uninsured which also appeals to me.
Question though.. would you pay for that or would you at all? If so, how much is reasonable per visit?
Thanks guys. I really want all feedback (even you Matt:)

Rude and salacious? OK, I'll give it a shot: Duke swallows.

How's that?

In other news, I'll be in North Carolina this weekend. Anyone interested in watching some Tar Heel basketball?

Sweep the leg, Roy, you got a problem with that?

no sinsei

Gee thanks, Neva. What I like about going to the doctor is to pay my $15 BCBS copay and not have to worry or even think about whatever it is the insurance company requires. If I don't get good service or good face-time with the physician, I go somewhere else. I like deciding who my doctor will be and not limited to a few or even a single choice.

arrive in san antone on friday. at the st. anthony hotel near the riverwalk. let's meet for a few pops if you make it down.

GO HEELS!!!!!!!!!!!!!!!!!!!!!!!!!

Thanks Matt. That's how I would answer too as a consumer of health care, however, what I am seeing in this area is folks are finding it harder to find that doctor they like or get good service because of the constraints on practice (ie 10 minute visit times, etc.). Sounds like you've been lucky and haven't run into that yet and also haven't had to do battle with the insurance company yourself (and it does happen to patients even ones who think they can just pay that 15$). There are so many drugs, tests, treatments that we now have to fight for or are just plain denied outright at times. BCBS is not nearly as bad as some but they have created many hoops lately that you probably haven't had to deal with yet.
One of our largest practices in town is shutting down and going to a "concierge" model where they charge a retainer fee of $1550 per patient to remain in their practice. I don't want to do that exactly but I am intrigued by the idea of losing the middle man in some way.
I do wish it was as easy for everyone to access care and feel good about the market place for medicine as it seems it is for you but that's not what I'm seeing or hearing from many folks.
One question you don't address is the deductable. If you already have to meet a certain deductable wouldn't you rather pay that large amount to somebody who spends more time,sees you on time, listens to you, follows up and is available to you? I have often wondered why chiropractors, massage therapists and the like can run an efficient and effective practice where people are seen on time and are generally happy with their care but we can't seem to do it with primary care (one answer of many - 10 minute visits and billing overhead).

Does anyone want to debate this article from the Atlantic Monthly?:

http://www.theatlantic.com/doc/200803/subprime

The topic is "Slums of the Future," referring to suburban development.

I love Random Topic Wednesdays! I am so excited about this weekend. Why, you ask? Well, first, Saturday morning we are getting up early, headed to LAX and flying to Maui for a week of fun in the sun. Fortunately, the Carolina game is second and we should be to our hotel by tipoff time. (My husband is actually quite nervous and wants me to research sports bars on the island just in case.) Then, Monday is my 38th birthday, and all I really want is a Carolina victory. There is nothing that would make me more happy than that!

Neva: I have some comments to share with you, but need to run out for a few hours. I will say that I love the fact that you are willing to be flexible and put your patients first.

Ian, What's up with the time stamp? It seems off.

Hi Neva. I have been reading about more docs setting up the retainer style practice up here in MD. How would that work exactly? Patient pays the amount up front, and then what? How would the costs of further treatment be handled? I would not really compare a retainer to a deductible. . . . personally, I do not mind paying out of pocket costs throughout the year as I reach the deductible, but I would not want to pay an upfront retainer. I would think it would be too cost-prohibitive for the average person.

One of the things that seems to be driving docs crazy is the increased cost of medical malpractice. In fact, my ob/gyn packed up his practice a few years ago and moved to FL because the med mal cost in MD was becoming prohibitive. Is that a problem where you practice?

For me, my interest in paying small copays and saving money through my health insurance is greater than my interest in a personal connection with my doctor. Two of my psychiatrists now do not accept insurance and have entered private practice. As much as I loved them, I do not love paying $110 a visit for medication management, so I have moved on. Likewise, I have moved on whenever my doctors announce that they no longer accept my insurance coverage. In the end, it is all about finances for me. . . especially nowadays.

Josie,

Not sure if I want to debate it but recommend diving deeper into "The Geography of Nowhere" or "The Long Emergency" by James Kunstler to get started on the riveting discussion of post-apocalyptic/Peak Oil scenarios.

Here is a thought-provoker:

Whose baby is cutest? Xtina Aguilera, J-Lo, Nicole Ritchie?

I think that little Harlow Madden is the cutest thus far. Although, once the photos of Halle Berry's baby are out, I am sure that Halle's baby will be the most beautiful baby EVER!

Neva,

A doctor who answers questions and doesn't seem in a rush to get you out of the office would be helpful...I think they rush people through so quickly, they stop paying attention, and that could result in mistakes. If they make one mistake, it's one too many.

But the fact is, it's very hard to tell whether a doctor is good or bad - you can only make a guess based on how knowledgeable he is and how well he listens.

neva - i would not have a problem with that kind of practice as a patient (where i had to file the insurance and would get a discount for paying cash at the point of service) as for how much i would find reasonable i guess the answer would be based on what the insurance would reimburse me. if i have a $15 dollar copay and i wind up having to file the insurance myself and the total cost to me is much higher than that i guess that would be a deal breaker.

i also realize from dealing with insurance companies that filing insurance is an absolute joke. i cant tell you how many times i have had claims denied for absolutely ridiculous things or coding errors and other minutiae that i dont think the average consumer could deal with. so then you would have alot of patients with insurance whose claims would be denied because they didnt fill the forms out properly and would be paying a much higher price than they should. who would they be pissed at then? the insurance co? the doctor for not filing the insurance and dealing with all that crap? both?

i really feel like the insurance companies are controlling the way docs practice medicine and i dont know what the answer is to that but i sure hope docs like you can figure it out!!!

Neva,
I am an internist and recently changed my practice to not being a non contracted provider with all insurance companies. for me it was either that or quit medicine. i make less money but i am much happier. i would be happy to discuss with you if you would like to know more about how our practice is doing things.

asd
unc - undergrad
ku - med school
will be pulling for the heels on sat night!

After falling for a friend's blog gag in which he purported the release of G-n-R's "Chinese Democracy" with downloadable mp3's (that turned out to be crickets SFX), I was successful in fooling a few friends on my Facebook 'status' page by claiming to have just purchased my ticket for the Led Zeppelin/Van Halen show at Soldier Field this summer. Wow, that was a long sentence.

About four people called asking me how they could get their tix.

Neva - i have this fantastic health care plan called definity: http://www.definityhealth.com/marketing/index.html

the way this works is i have zero copay, and my premiums are paid into a pool of money that accumulates over time. so if i have 3 years of good health and then one doozy illness, the 3 years pool of money i've accumulated is still available for me to use toward services. i'm oversimplifying, but you get the idea. i can see any doctor with no referrals, and get any med they perscribe, generic or not, also free. and there is a backup traditional managed care type copay if i was to exhaust my funds. it's a little complicated but it has been fantastic so far.

i think that is the direction most managed care plans should go, if possible.

aside from that, i have also used something called 'doctors on call' where they make housecalls or take immediate appointments, which really helps with my schedule: http://www.sfoncall.com/ at this practice, it is an upfront fee and you have to submit claims to your insurance company yourself.

i think these are two outside-the-box models that i have found really work.

i am a choosy consumer of health care services, so what i want most is flexibility to see multiple doctors and tiered services depending on what i want for a particular service. so for example, i prefer a female OB GYN in a female owned and operated practice, and preferably with certified nurse midwives. i travel across the city for that. for a foot problem i sought out the orthopedic surgeon who works with the Oakland A's. for pediatric services, i am adamant about using the same doctors who have seen my kids since they were born, and i would follow those doctors to a new practice if necessary. i travel across the city for that too.

but on the other hand, i will pay a premium for same day urgent care designed around my schedule or a house call when i know i just need an update on allergy meds or an antibiotic or something straightforward like that and i am short on time. Otherwise for that type of basic service, i am more likely to just go to the generic family clinic nearby where i expect to end up with a nurse practitioner.

Neva -- I've unfortunately had an up close encounter with the medical profession the last few weeks. My husband (healthy 40 yr old runner, etc.) got the flu. This progressed to a serious case of pneumonia. He was hospitalized for 4 days and is still on oxygen. It's been quite the education in the inefficiencies of the doctor/hospital system. First doctor heard the fluid in his lungs in his 5-minute visit, but my husband being the macho guy didn't demand an x-ray so things continued to go downhill. We called a nurse line over the weekend when he started wheezing (didn't want to go to the Emergency room) who said just wait it out. When he finally got in to see a doctor, things were pretty bad. Nurses, etc. at the hospital were great, but we didn't get clear answers about what what happening. I have an High deductible/HSA plan (my husband has traditional insurance). My plan does its job of making me seek out lower-cost options. Most startling thing has been the range of payments for a simple procedure. I never realized that the cost for a doctors visit or procedure varies based on what insurance you have -- not co-pays, actual costs for service. It reminds me of buying a car. I think there's a business model out there for a CarMax/Saturn medical practice where you know what the costs are up front. Also - I'm hopeful about some of the potentials of technology. Would be great to have your medical files where you can access them electronically.

I am lucky enough to have Neva as my doctor and in the short time I've been her patient, I'm sold. I have never had a doctor spend as much time with me, give me their cell number and truly mean it when they said to call if I needed them. I'm not sure how to handle the insurance business, but if it meant changing our program to stick with a doctor I love and trust, I'd do it.

Wow, thanks guys! I appreciate the input and also the kind words from you SLS.
I wish I knew an easy answer. There are a lot of unhappy doctors and patients out there if only we could fix the system to help both. I'm trying to think creatively and want to do everything I can to keep my current patients but look at a better model. There are lots of interesting models out there but many are really designed for those with lots of available extra funds (ie the retainer fee practices, cash only etc.). I totally get that folks who pay lots for their insurance already don't want to pay even more to see doctors but we also have to deal with the issues kjf and sharon describe where insurance companies don't have to pay you. Denying claims is almost the norm in most cases and without any explanation. Neither patients nor doctors really know what to expect from medical charges/fees/costs so how can you really plan a business model around totally unknown reimbursement? My ultimate goal is to have a practice where I treat people the way I'd want to be treated or the way I'd want my family treated, but it's really hard to make that happen and break even, in primary care at least.
Anyway, as usual, ya'll are a great bunch of thoughtful folks and I appreciate your perspective and advice. Also, thanks Ian for letting me air my own issue today!
asd - would love to talk to you. Perhaps Ian can put us in touch?
LFMD - I'm thinking those Jolie-Pitt twins will be the cutie-est?

neva,
one great thing about my current practices style is that i have some flexibilty in charging the patient. there were a few hmo seniors that could not change to medicare... i see them for free or $10 (their usual copay). there are also some previous patients and new pateints that don't have the funds to see me. for these people i see them for free or charge soemthing like $25 for the 20 minute office visit.

ian - please pass my email on to neva

asd