No Insurance Here

by timryanmd

Years ago, the doctor was paid directly by his patient.  While not a perfect arrangement, it worked very well for doctors and patients.  If someone was ill and didn’t have the money to pay, the doctor would help them anyway and receive payment later or not at all.  Patients were grateful and if they couldn’t pay, they would probably send other patients who could.  Doctors’ incomes didn’t suffer too much and they had great satisfaction in helping their neighbor or a stranger in need.  This is still the way it works at my office.

Taking money from an insurance company to treat a patient never seemed right to me.   It seems simple and honest for me to receive payment directly from the patients I treat.

Some might object, “but I can’t afford to pay the doctor!”  You might be surprised.  Let me show you a few reasons why it is better to pay your doctor directly.

First of all, you should actually be a little uneasy when a doctor is paid by a third-party because that means his loyalties will be divided.  The cold fact is that the doctor needs to accommodate those who pay him lest he go out of business or find himself unemployed.  Therefore the doctor will ultimately do what the insurance company says, and the insurance company requires doctors to do all sorts of irrelevant and wasteful tasks that have nothing to do with your care.

Third parties can also complicate reasonable decisions.  Imagine the scenario where a patient might have a simple, straight-forward problem like a tension headache.  If they are paying their own bill, they will be relieved when I tell them, “this sounds like a simple tension headache.  Try these few things and just let me know how things go.  You do not need a lot of tests or an MRI….”

If they have insurance, they are more likely to ask about the “free” MRI “just to be sure”.  And the doctor is more likely to order it.  Most of the time tests like this are a waste of time and money.

In addition, imagine how much money your doctor actually spends on overhead to deal with insurance!  He must purchase computers, software, printers, phone lines and pay for office space and staff in order to manage the insurance company.  What a headache.  Those costs are passed on to the patient one way or another.

Not using insurance can also make your visit safer.  Insurance rules are burdensome and confusing. They can turn a simple encounter into a labyrinth of documentation, approvals, unnecessary testing and other distractions that can cause chaos at your doctor’s office and more mistakes are likely.

Your doctor’s visit should be private.  Despite all you hear about HIPAA and patient privacy, the ironic fact is that the records in almost all doctor’s offices and hospitals are anything but private.  If you have insurance, your name is attached to a lot of billing and diagnosis codes that can be seen by a lot of bureaucrats who work for your  insurance company and the government.  Your data is not private unless you come to my office or one like it.  I do not send any information about you anywhere unless you tell me to or I am ordered by the courts.

You will be surprised how much farther your dollar will go and how much better your medical care will be when you pay directly. Look here and here for examples.

Have any questions? Just call 770-382-1984 or visit.

ER visits on the rise

by timryanmd

An article in WSJ points out that ER visits are on the rise.  This is the opposite of what was intended by the Affordable Care Act yet it is predictable for several reasons.

1. Primary Care doctors are already busy and already have a difficult time seeing sick patients urgently or on the same day.  They send patients to the ER.  This pattern will get worse because the ACA pays doctors more to do preventative care stuff like check cholesterol levels or order mammograms or do an Annual Exam.  Primary Care doctors will therefore fill their schedules with the preventative care visits and have less time to see sick patients.  The sick people will funnel to the ER more.

2. People with the exchange plans have limited options for a primary care physician.  The networks are small and the “primary care” doctor may not be nearby.  This might change over time, but I don’t think so.  The local ER will be an option.

3. Most of the new insurance plans have a high deductible (which is good) and unless they go here they won’t be to afford to see their doctor so they will go to ER .  Yes, the ER is much more expensive but in reality it is often “free” to the patient because they just don’t pay the bills.  The ERs and hospitals are required to see all-comers no matter what.

Most of the effects of the ACA will be the opposite of what was intended.

Quality at the VA

by timryanmd

The VA hospitals were under pressure from the top of the organization to increase the number of patients who could be seen within 30 days.   The VA employees quickly rigged a system to make the charting look like people were being seen timely when they actually weren’t.  Yes, one way to improve quality of care is to cook the books.

There is intense pressure to make changes like this because there are countless regulations that flow downhill from the bureaucracy.  Many of the regulations are silly and almost all are burdensome to an organization and ultimately result in compromising care rather than improving it.  Fudging the numbers and making something look different on paper is unfortunately common.

Should I take Cholesterol Pills?

by timryanmd

A lot of people wonder “Is my cholesterol too high?  Do I need to take a cholesterol medication prevent a heart attack?”  The answers are not that simple but the chance that taking a cholesterol pill (Statin) will help you is  low even if you’ve had a heart attack.  Plus, taking Statins is not without risk.

If you have a heart attack, the studies (which are arguably biased) show that taking a Statin will help prevent a second heart attack (secondary prevention) in a small percentage of people.  If you compared two groups of people and one group took a Statin and the other took a sugar pill for 5 years, the first group would have about 3-4% fewer heart attacks and maybe 2% fewer deaths.   In other words, about 96% of people treated with a Statin would not benefit from taking it.  But 4% would benefit.  As a doctor, I will have to treat 83 patients every day for 5 years with a Statin to prevent one death.

Other interventions are much better like committing to a Mediterranean diet, exercising, enjoying your work, or stopping cigarettes.

If you’ve never had a heart attack, the benefit of Statin drugs is not settled, but if they do prevent heart attacks, the percent of people who would benefit is very small.

TheNNT.com has brief and insightful summaries of the evidence.

This graph from the Framingham study is interesting.  According to Framingham, a Cholesterol of 210 was the most prevalent reading for those who never had a Heart Attack and 225 was the most prevalent reading for those who did.  There is obviously some correlation between elevated Cholesterol and increased risk of heart attack.   But correlation does not mean causation.  High cholesterol does not cause heart attacks.  If it did, the graphs would look much different.

The 2013 Cholesterol Guidelines are an improvement in several important areas.  I will comment on those guidelines in another post.

Doctors won’t like Medicare transparency

by timryanmd

It seems that next week CMS will be making public how much it paid individual doctors.  Doctors won’t like that.

Even the AMA (which hardly represents doctors) is against it.  AMA president Ardis Dee Hoven said:   “The AMA is concerned that CMS’ broad approach to releasing physician payment data will mislead the public into making inappropriate and potentially harmful treatment decisions and will result in unwarranted bias against physicians that can destroy careers.”

That is pretty high drama.  It is also ironic because the AMA promotes without reservation the use of other CMS data like their Quality Measures and ICD-9 codes (soon to be ICD-10).  Have you heard of ICD-10?  This is the WHO and AMA’s coding book which turns your doctor’s visit and your diagnosis into some kind of weird digit and phrase that are difficult to understand, but easy to send throughout the electronic medical “system”.  All doctors who bill MCR or insurance are required to use the coding for billing and documentation.  ICD data at the point of entry is inaccurate and often intentionally manipulated.  Making reports based on the faulty ICD data is the obsession of the healthcare bureaucrats like the AMA.  They trust that data.

So why would the AMA claim that CMS’ data when it pertains to payment could be misleading?  The fact is CMS’ payments to hospitals and doctors is probably the most accurate and the least misleading of any data it has.

I think the data should absolutely be made public so we tax payers can see how our money is being spent.  We should be able to see all payments to Government contractors.  Doctors are not above reproach.

Concierge Practice?

by timryanmd

I’m occasionally asked, “Is your practice a Concierge practice?”  My answer is, “Yes and no.”

It depends on how you define “concierge”.  If you define concierge as a practice that provides individualized care, great service and the direct attention you deserve in a doctors office, then yes that’s what I do.  Most current offices cannot do this well because their minds are cluttered with regulatory rules, formularies, referral requirements, ICD-10, CPT codes and the dozens of other things that are imposed by the “payors” who are other than the patient.

Not me!  Since my patients pay me directly I am saved from the misery of the above.  Payment to me reinforces my professional instinct and the Hippocratic ethic to advocate for patients and treat them the best I can.  Direct payment is honest and simple and both the patient and doctor are generally satisfied.

“Concierge” has taken on a slightly more precise meaning in the last 10 years or so.  Concierge not only describes practices that “place patients first” and provide “personalized” or  “attentive” care, but in real terms it describes a practice where patients pay a fee, usually about $1,000/year.   This allows the doctor to keep a small number of patients in his practice, say 500.  Such a small patient load allows the doctor to spend a lot more time with the patients and truly provide individualized and very attentive care.

I do not have this type of practice for several reasons.

1.  One premise of the Concierge model is that you can prevent diseases by regularly seeing a doctor.  Generally, I don’t believe this is true.  You can absolutely prevent diseases by changing your lifestyle and for that advice you are probably better off going to a good dietician, fitness trainer, chiropractor or just use your common sense.  You can also go to a good doctor (like me) who can give you advice, but you don’t need to pay $1,000/year for that.  You can just schedule an appointment.

2. Many people who truly need medical help also do not have the resources to pay for entry to a Concierge Practice.  Who is going to see them? People of humble means or who are truly sick need the most attention and I think my system can do that best.  I prefer to keep my prices reasonable and a good value for everybody.

3. People who are overly obsessed with their medical care, but are really healthy, would gravitate to a Concierge Practice.  I don’t enjoy seeing these kinds of patients, nor do I help them much.

Concierge is a great alternative style of practice that fills a need and I’m confident it will grow.  I wish it well.  I hope good and qualified doctors will continue to establish their own private practice, each different from the other, so patients can best find suitable care.

Free markets are best able to provide for the infinite desires of the consumer.

Gospel

by timryanmd

And Jesus returned to Galilee in the power of the Spirit, and news about Him spread through all the surrounding district.  And He began teaching in their synagogues and was praised by all.   And He came to Nazareth, where He had been brought up; and as was His custom, He entered the synagogue on the Sabbath, and stood up to read.  And the book of the prophet Isaiah was handed to Him. And He opened the book and found the place where it was written,  “THE SPIRIT OF THE LORD IS UPON ME, BECAUSE HE ANOINTED ME TO PREACH THE GOSPEL TO THE POOR. HE HAS SENT ME TO PROCLAIM RELEASE TO THE CAPTIVES, AND RECOVERY OF SIGHT TO THE BLIND, TO SET FREE THOSE WHO ARE OPPRESSED,  TO PROCLAIM THE FAVORABLE YEAR OF THE LORD.”  And He closed the book, gave it back to the attendant and sat down; and the eyes of all in the synagogue were fixed on Him.  And He began to say to them, “Today this Scripture has been fulfilled in your hearing.”- Luke 4:14-21

Jesus came to earth and breathed life to all those who believe in Him.  He suffered on a cross and died for sins.  He rose from the dead and is now with God the Father.  Repent of your sins and believe in Jesus.