Dr. Chad Costley's Blog

Insurance and me - so far so good...

2010-04-30T13:13:00.003-04:00

Two months ago I made the difficult decision to start accepting major medical insurance at Ponce Primary Care. We became convinced that our use of technology and our commitment to keeping our overhead low would allow us to maintain the pillars of our practice (accessible, personalized and comprehensive care) while billing insurance companies for patient visits. This was a major change as in my previous professional life I came to see medical insurance and exceptional primary care as being mutually exclusive. Good news. The two month scorecard = so far so good.

We've found billing insurance companies to be surprisingly easy. A big part of this is that in keeping our promise to limit the size of our practice we generate fewer bills, which of course lowers the absolute number of hassles. Our paperless office is also a big deal as large insurers do much better with electronic claims. We don't have to translate my number scribbles into claim forms - an expensive and error-prone process that handicaps many practices.

We still offer simple visit fee schedules for those without insurance and membership plans for those who want services that medical insurance doesn't cover (direct cell phone access to the doctor, phone visits when appropriate, after-hours appointments, etc), but we've made it easier for many to get exceptional care by broadening the payment options.

I still believe that in an ideal system medical insurance would be limited to covering catastrophic events and we would all pay directly for routine care. The entire system would be much less expensive given the dramatically decreased cost of administering such a system. We could easily finance a safety-net program for those who truly couldn't afford care with a fraction of the savings. However, the recent healthcare law, if implemented as written (a big "if"), will dramatically increase rather than limit the role of insurance in healthcare. I'll continue to advocate for reversing this trend. In the meantime, visit www.ponceprimarycare.com to see how we're balancing an imperfect system in order to provide our patients with the best primary care I can imagine.

What we value...or don't.

2010-01-28T12:36:00.003-05:00

An anecdote from the front lines of primary care...

A woman calls our office asking "do you fill out these sports physical forms?" No established relationship with the practice - just a mom needing her daughter's "forms filled out" for a sport starting the next day at an expensive private school nearby. "We have a pediatrician...but they can't see us today? Can you?" Given my practice structure we're able to offer a sports physical later the same afternoon. "How much will it cost?" Eighty dollars is the answer...much less than we would collect from an insurance company if we billed them for such a visit. "Eighty dollars! Walgreens will do it for $60!"

Do they have doctors at Walgreens? Is there any value at all in having your daughter's heart listened to by someone who went to medical school? Is there any value at all for a practice's ability to see someone on short notice? Does quality primary care still matter...or should we just go the "forms department" at our local convenience store for our care? Over $20k per year being spent for this girl's high school education and I have to justify why the care I provide as an accessible, quality physician is worth $20 more than what is purchasable at Walgreens.

I wish stories like this were rare. The truth is that primary care has been so systematically devalued by the government, third-party payors, medical schools and even many physicians that this attitude is neither unique nor surprising. We need to do a much better job of explaining that health outcomes are significantly improved when primary care physicians are the first point of contact for patients. We need to do a much better job of explaining the various roles of physicians, nurse practitioners and physician assistants and when they are and are not interchangeable. We need to do a much better job of enlisting our specialty colleagues in the fight to save primary care in this country.

What's in a name?

2010-01-07T13:03:00.007-05:00

What exactly is a family doctor? How about an internist - is that a person who specializes in an organ called the "intern"? If so, where is this mysterious organ located? What's the difference between a pediatrician and a family doctor who takes care of kids? Fundamentally, people need to know where to go first when they get sick or want a doctor to help them stay well. The divisions we physicians have created within primary care don't help patients answer this question.

The organizations who claim to represent these groups of doctors, namely the AAFP (American Academy of Family Physicians), the ACP (American College of Physicians) and the AAP (American Academy of Pediatrics) have failed to effectively coordinate their efforts to support primary care doctors. Too often, we've spent our energies promoting narrow agendas. Pediatrics claims the ethical ground as the ultimate advocates for kids. Internal medicine claims the "evidence" ground; they're rightly serious about the science of disease. Family practice claims the stump for the doctor-patient relationship and treating the "whole person."

All of this is noble and good-intentioned but fails to aim at the right target. Primary care is dying in this country. The average age of primary care doctors has increased significantly in the past 10 years and alarming percentages of those doctors want to retire early. Quality medical students are avoiding primary care to a degree never before seen. The vast majority of young doctors finishing their residencies are choosing to extend their training by a couple of years in order to specialize. It's an unsustainable situation largely ignored in the debate on healthcare. Until the primary care physician community that includes general internists, pediatricians and family physicians gets it's act together to advocate in a united way for our patients, the problem cannot be solved.

The size of our patients and whether we treat whole families or specific age ranges of patients may determine what tests we take when we become board-certified. It may have dictated which ICU we haunted during the endless nights of residency, but it does not define our responsibility to society. We hold a sacred trust to advocate for a system that supports accessible, comprehensive, personalized and coordinated primary care for patients. We need to get collectively focused on that. We need to stop angling for relative respect under the disrespected umbrella of primary care and start collectively leading healthcare transformation. Our patients deserve and want just that.

Enshrining the status quo...

2009-12-22T09:41:00.003-05:00

We can tell a lot from the groups that have come out in support of the Senate's insurance reform bill and from those whose "opposition" is muted and disingenuous. The American Medical Association supports it, but threatens to withdraw support if the Sustainable Growth Rate formula isn't overhauled. Translation: We like the current dominance of fee-for-service reimbursement through third-party payors because it protects the incomes of most of our members who are specialists. We just wish the formula paid us even more.

The American Hospital Association supports it, but would also like provisions added that reduce the threat of Medicare reimbursement reductions for hospitals with high readmission rates. Translation: Like the AMA, we too like fee-for-service reimbursement based on volume of procedures and tests rather than quality. The system of disease focus rather than health focus serves us well as we're clearly in the disease business.

The Insurance industry publicly "opposes" the bill under the veil of "we care about our members - and think their premiums are going to go up." Simultaneously, they've quit spending much money or energy on stopping this thing, which they could clearly do if they wanted as a number of Democratic Senators are tied very tightly to the insurance lobby.

It's a classic and usually effective political strategy. They've set up the "I told you so defense" in advance so they can raise insurance rates after the no-preexisting conditions rules kick in. They then profit nicely from increasing premiums while the new laws force younger, typically healthier-than-average, and thus profitable people to buy insurance they previously decided they didn't need. Beautiful perfect storm. The Democrats provide the publicity cover, and the Insurance industry gets a mandate to take over even more of the health care pie.

Speaking of pies...by what logic does the growth of this pie slow under this plan? We provide more people with someone-else-pays-for-it access to a system still based upon doing rather than thinking, testing rather than listening, and treating rather than preventing. Any claims of cost savings are completely baseless...and cost containment is the whole deal. There's no reform without it.

Marital status needed to make an appointment?

2009-12-17T11:06:00.003-05:00

Bizarre experience today as I again experienced as a patient the parallel universe that is healthcare in the U.S.

I'm turning forty this year so decided to make an appointment for a physical with my primary care doctor. I called the office and was told that the next physical available was at 3:30 pm six weeks from today. Not commenting on the lack of reasonable access, I asked if an early morning appointment was available so I wouldn't have to fast all day before my visit. "Why does that matter?" asked the receptionist. I can't imagine why it would be more unpleasant to not eat until 5:00 pm than to delay breakfast until 10:00 a.m. The receptionist couldn't imagine that either. She then informed me that the next morning physical available was in April. I'm an established patient of the practice that espouses access, quality, etc. all over it's website and they can't see me until April.

So I call another practice...a big one here in Atlanta with a strong, serious reputation. Access is better (three weeks rather than six until their first appointment), but the person on the phone proceeds to "get my information." Included in this antiquated process is the question "Are you married, single or divorced?" What? Why is my marital status the business of whoever answers the phone at a doctor's office? How is it relevant to my making an appointment with a physician? In addition, what if I were "none of the above"? I was tempted to say, "I'm a gay male previously divorced with six kids, now married in Massachusetts which isn't recognized in Georgia - so just call me single." Would have been great to hear the silent pause after that. Many of you know that I'm neither gay nor divorced and have two kids. I've only been to Massachusetts a couple of times in my life. The point is that the question would never be asked in any industry that treats clients like customers. It's rude - like a lot of healthcare in the U.S.

Primary Care's Toxic Environment

2009-12-20T07:00:00.003-05:00

In his blog (linked below), Dr. Richard Figaro captures the toxic environment that is killing primary care in this country.

Crocodile Tears Over Primary Care - Lamenting Primary Care

I agree with his points but wish he would emphasize that primary care doctors are not powerless. Patients respect and value what we do and in my experience will pay us directly for their care. Refusing to submit to the nonsense that DrRich describes in his blog is the most important step to keeping our costs low so the price of great care is accessible. See my practice website, www.poncepreventive.com, for specifics on how this can work.

Thank you Senator Lieberman

2009-12-16T09:38:00.010-05:00

There have been some good ideas and some horrendous ideas appear this year as part of the health insurance debate. Expanding Medicare was probably the worst apple that has fallen from the idea tree. It now appears we were one Senate vote away from significantly expanding the wasteful, bankrupt pyramid scheme that is Medicare. Senator Lieberman has shown real political courage this week and done the country a great service by halting the nonsense.

Medicare a "pyramid scheme"? This may sound harsh, but the fit is too tight to ignore. In a pyramid scheme, current benefits are paid to previous investors out of funds provided by current investors. That works fine until the number of new investors becomes insufficient to pay the current benefits at which point the scheme collapses. Hmmm...sounds like Medicare today to me. As the baby-boomers age and retire, the cost of their healthcare expands as the number of workers paying into the system declines. It would be hard to call this a pyramid scheme if it were just bad luck or circumstances, but we've known for decades that the demographics of the U.S. would lead to this. We just chose to do nothing about it.

We have a moral contract with our seniors to provide them with accessible, quality healthcare. Medicare is our very flawed attempt to honor that contract. The problem is that Medicare, like most health insurance, is procedure driven. Doctors and hospitals get paid more for doing than thinking, more for testing than listening, and much more for treating than preventing. The evidence is found in answers to simple questions: Is it easier to find a surgeon who accepts Medicare or a primary care doctor who accepts Medicare? Is it easier to see a nutritionist and have Medicare cover the $100 fee or have Medicare cover the thousands of dollars of cost when the preventable heart attack occurs? Does Medicare pay doctors for outcomes like the health of their patients or inputs like the tests and procedures performed? The answers to all of these questions are disappointing.

Expanding Medicare in its current form would quicken the already alarming reduction in access to quality primary care in this country. Doctors are leaving and avoiding primary care in droves. The administrative trivia imposed on primary care by the byzantine system of coding, justifying, and compartmentalizing care has made primary care a particularly unappealing professional choice. We need to create and finance a system that reverses the current incentives and priorities. Adding millions of people to a collapsing system looked for a week like a way to pass a bill, but the approach made zero sense if the goal is to actually reform the system.

What to Make of the Mammography Controversy

2009-11-19T10:49:00.004-05:00

The recent change in mammogram recommendations by the U.S. Preventive Services Task Force is long overdue, and the controversy surrounding it highlights an important problem in healthcare in the U.S. Namely that we are terrible at setting priorities.

Without summarizing all of the details, the task force has interpreted the available data and now recommends that mammograms for women at normal risk for breast cancer start at age 50 rather than 40 and be done every two years rather than every year. The U.S. was way behind on this, most countries in the world avoided the mistake of exposing average-risk women under age 50 to unnecessary radiation a long time ago. In addition, the task force has recommended we stop teaching women to do self breast exams (a time-honored practice that has led to a lot of worry and anxiety in women but has never been shown to save lives.)

The reaction to this recommendation has been loud and predictable. The American Cancer Society, numerous breast cancer advocacy groups, politicians, and doctors who get paid to diagnose and treat breast cancer have responded by calling the new recommendations "reckless", "financially driven" and even "the first step in the rationing of healthcare." The simple truth is that there was never good data supporting the benefits of routine mammograms prior to age 50. The practice evolved within a system in which money flows when tests get done whether or not they are a good idea. Breast cancer screening is big business in the United States, and a recommendation to decrease the screening for it by at least 50% threatens a lot of incomes.

To be clear, there are women alive today because they got mammograms prior to age 50. In the information age, it is easy to locate stories of a woman saved by an early mammogram. It is more difficult to find the significant harm done by routine screening. For example, women younger than age 50 who have an "abnormal" mammogram go through significant psychological stress during the subsequent work-up which in the vast majority of cases shows no cancer. The work-up may include breast biopsies which involve pain, cost and some risk from the procedure itself. There is both a financial and distraction cost of all this that takes money and energy away from other public health needs such as decreasing the rate of heart disease which kills many more women than does breast cancer.

The most intuitive way to interpret the data surrounding mammograms is to look at the "Number Needed to Screen." Simply, this number tells us the number of women under age 50 we would need to screen with annual mammograms and for how many years in order to save a life. In the case of breast cancer, the Number Needed to Screen is approximately 2,000 women screened annually for 10 years. Therefore, we save one life for every 20,000 mammograms performed on women younger than age 50. Of these 2,000 women about 50% or 1,000 of them will have to endure the consequences of an "abnormal" mammogram during the 10 years. Another way of saying this is that for every 1,000 women under age 50 who have abnormal mammograms during the 10 years one life will be saved.

Admittedly, if you're that one life the statistics above don't concern you or your family. That logic is always (including this week) used to justify screening for rare problems. However, the problem with that logic is that it ignores the harm done to the thousands of women who get abnormal mammogram results but have no cancer. The logic also pretends that our resources are infinite and that screening for one disease has no effect on our ability to prevent other diseases. In fact, if the money spent on mammograms were directed to more pure prevention strategies (improved diet, decreased smoking, increased exercise, etc.) fewer women would die not only of breast cancer but of the other diseases caused by the same lifestyle problems (heart disease in particular).

We may not be too far away from the day when screening technology for breast cancer improves to the point where less harm would be done by screening younger women and the benefits would therefore outweigh the risks. However, at this point we're stuck with a screening method that exposes women to radiation, fails to detect small but aggressive tumors, and leads to a lot of false "abnormals." In this context, the task force's recommendations are right on target.

What does healthcare cost? Who asks that question?

2009-11-10T10:03:00.006-05:00

Hi all:

I saw an Orthopedist yesterday for an ankle injury. It was a great reminder of one of the primary problems with healthcare; no one knows what anything really costs. My wife and I have high-deductible insurance through her employer. We have it to protect us against the unlikely but possible financial burden of being very ill or injured. We don't expect it to pay for our primary care or basic medical needs. Similarly, we don't expect our auto insurance to take care of our tires, oil changes and tune-ups. Insurance is a lousy way to finance commonly occurring events. Our society's attempt to use health insurance to finance most services has been a disaster in terms of increasing healthcare costs. Yesterday is a great example of why.

During my visit I was focused on my visit and briefly forgot that ultimately I'm the one paying for services. The doctor's assistant ordered 7 x-ray views of my ankle before the doctor even saw me. I should have asked the obvious questions. How much do those cost and do you really need all of them? Of course, the person ordering them (i.e. selling the services) would have had no idea. We would have had to disrupt the clinic flow to go to the biller to figure that out. However, I never buy anything else without knowing the price. Why is it so natural to do so in a doctor's office? As an aside, at the very least the two views of my heel were unnecessary as the injury is nowhere near the heel.

I regret that I wasn't overly concerned about this until I got home and my wife reminded me that we are way below our deductible for this year, so I really was the one directly paying for those x-rays. In this case, I wasn't passing the cost off to others who overpay for their insurance premiums because too many tests get ordered unnecessarily in doctor's offices. So there I was, reading a novel late at night and wondering how much I had paid for the x-rays I had purchased that day. The feeling was worse because I knew as others might not that at least some of them were unnecessary.

This morning I resolved to figure out how much I was going to owe BCBS. Here's what I found out. The practice would have discounted the fees by 30% if I had paid them myself rather than using my insurance. Sounded at first as if that's the way to go, but I was then told BCBS would only be paying the practice 40% of the listed fees for the service. So I get a 60% discount on the "listed fees" through BCBS or 30% directly. In effect, BCBS is getting a "volume discount" in exchange for the number of patients they send to the Orthopedist. Self-pay patients get a 30% "discount" on a listed price for services that no one actually pays. This begs the obvious question - what is the purpose of the listed fees if no one pays them? That's easy of course. The list price has to be set high enough that the practice can keep the lights on at the 40% reimbursement rate. So the fact that insurance is involved drives the price of care up for everyone except those paying insurance premiums each month so that the insurance companies can negotiate the prices back down for their "members". Does this seem like an efficient way to finance anything? By the way, I never did find out what the x-rays actually cost. No one knows; I'll find out in a couple of weeks when BCBS sends me a bill.

At Ponce Preventive Care, we have a clear fee schedule posted on our website (www.poncepreventive.com) and in the practice. Our patients never wonder what they're paying for what they're receiving.

Great HealthCare Article

2009-09-21T16:26:00.004-04:00

Hello:

This months' cover article in the Atlantic is a great summary of what's wrong with healthcare in the U.S. and how to start working towards a fix. The article very smartly points out that expanding health insurance, whether public or private, is a big mistake. It isn't a short article, but it's worth the read.

http://www.theatlantic.com/doc/200909/health-care

2009-09-21T16:17:00.004-04:00

Guns and Butter, or Not

One of the first lessons in an introductory economics class is about “marginal utility.” The basic premise is that reasonable, informed people can make rational decisions about their willingness to trade one thing for another. We make decisions about what we value and trade our resources for what we lack. As we collect more of something, we value the next bit of it less in comparison to something we lack. The classic teaching example involves guns and butter. If you have a lot of butter stored away, you might trade some of it for a gun to protect the shed from the armed and hungry marauders on the other side of the hill. If you have a bunch of guns but are hungry…you get the idea. Let’s pause early for a big Yawn! Now stay with me, because this matters when it comes to healthcare.

Marginal utility is one of the primary bases for all of economics. Without rational consumers making informed choices between the money they have in their wallet (or the butter in their shed) and something else they want or need our understanding of trade falls apart. However, when it comes to healthcare, the theory doesn’t work. If we blindly apply the lessons of economics to health, we waste money and human beings suffer. Here’s why.

When I walk into a shoe store, I can look at the selection, try a few on, and make a reasonably informed decision about my preference for the money in my wallet or the brown loafers with the penny-holder (remember those?). I’m even somewhat covered, because if I get home and decide they don’t fit, I can probably bring them back. I can act rationally based upon my preferences and my “marginal utility” for a new pair of shoes. However, when a patient comes to see me for a cough, if I’m the “seller” of medical services and they’re the “buyer”, I’m in a very powerful position. The shoe salesman would be jealous. Let’s play act for a bit…

Doctor: “Well Mr. Jones you have a cough. I’ve examined you and it’s probably just a cold and will pass. However, there’s no way to know for sure that this isn’t pneumonia or even lung cancer. It’s very unlikely, but we’d need a chest x-ray to be more confident. What would you like to do?”

Translation: I know this is just a cold, but I like to be ‘conservative’ and cover all my bases. I’ve been busy seeing 30 patients a day for the last 10 years and haven’t really kept up with evidence-based indications for chest x-rays. An x-ray costs some money, but it’s not my money, and it’s not really his money either because he has insurance. Besides, he’ll think highly of me because I’m a thorough doctor who doesn’t send patients away without ordering impressive tests.

Mr. Jones: “Well doc…I don’t really want to die. My insurance will cover the x-ray, so let’s do it to be sure. By the way, thanks for being so thorough. I’ve gone to other doctors who didn’t even bother to order a chest x-ray.”

Translation: Marginal utility is out the window. “I’m no longer rational…I’m scared! He has a big diploma on his wall, wears a white coat and said the words ‘lung cancer’ followed by something I barely heard about it being “unlikely.” I’m getting a chest x-ray today. Thank goodness I pay $850 a month for health insurance so that I don’t have to pay the $150 the x-ray will cost. I like this doctor. He takes things seriously.”

Whether the doctor profits directly from the chest x-ray is beyond the point. There’s no medical need for the x-ray. In fact, over-testing causes medical harm (more on that in future articles). Overuse of technology largely drives the cost of healthcare. Cost keeps us from providing basic care to everyone. Cost forces employers to eliminate jobs to cover their healthcare costs. Cost of healthcare causes almost half the personal bankruptcies in the U.S. each year. Cost tears money away from other necessities like better public schools. Unless we can control cost, we cannot build a quality healthcare system.

Competition drives cost down in almost every industry, which is why you’ll hear phrases like “consumer-driven healthcare” thrown around as potential solutions to our cost crisis. The idea is that consumers will make rational choices with their money and force medical providers to charge less and order fewer expensive tests. However, convincing evidence shows that in healthcare competition drives cost up in the long term with no improvement in quality. Healthcare defies the normal rules of economics because Mr. Jones is not a rational consumer trading guns for butter. He’s a scared human being who can be directed by a hospital, pharmaceutical company, medical device company, or a physician to direct some of the trillions of healthcare dollars their direction in the hope of taking away the fear. Making things even worse, Mr. Jones has a false view of quality care, remember this is a “conservative’ doctor who ‘takes things seriously.” In fact, the doctor here is recklessly ordering unnecessary tests that can do harm. This is a recipe for high cost, poor quality care. It’s exactly the recipe we’re cooking daily in the U.S.

Arguing About the Wrong Things

2009-09-21T16:08:00.002-04:00

Arguing about the Wrong Things

The current debate grabbing our nation’s attention is not about healthcare. The “healthcare” bills in Congress, the President’s townhall, “healthcare” meetings, etc. have very little to do with health and almost nothing to do with care. They are an effort to change how we pay for our current mess, but what we pay for something is very different than the something itself. Words matter. So let’s be careful we don’t mistake “health insurance” for “health care” and make a very expensive decision that further endangers our health.

So what is the It that is healthcare in the U.S? What do we want It to be? We should answer those questions before enduring a divisive fight about whether the government, employers or individual families should finance It. It is a bad idea to buy something, especially a very expensive something, unless you have some idea of what you’re getting. This truth makes the debate about who should pay for healthcare a distracting sideshow. Whether the money is funneled through private or government insurance programs or comes directly out of corporate or family bank accounts matters much less than whether we buy a system that works. Ultimately, individual citizens will pay for the healthcare we receive. We’ll either pay directly or indirectly through insurance premiums, taxes, or lower incomes. There’s no free lunch here so it might be worthwhile to think about what we’re ordering before debating how to split the bill.

So here’s the good and bad news.

The good news is we don’t need to fix a “broken healthcare system”. The simple reason is we don’t have a “system” at all! A system implies design. The assumption in a system is that someone or a collection of someones thought through what the system should do and how it should be put together. Henry Ford designed and built a system to make cars efficiently. That is not the history of healthcare in the U.S.

What we have is a collection of habits, profit centers and non-profit organizations presented in a bewildering maze of chaos. As patients you experience the inefficiency of this all the time. You feel it when you fill out forms repeatedly. You suffer from it when your doctors have no way of efficiently communicating with each other and no strong inclination to even try. The examples are endless. It troubles me that physicians will rarely address this truth. We generally prefer to hide behind silly and harmful clichés like “We have the best healthcare system in the world.” There’s little evidence to support such a claim, but the American Medical Association loves it and has done a good job of teaching it to too many influential politicians. Doctors generally like it because it pats us on the back for the care we do provide and helps maintain the status quo that supports our lifestyles.

The bad news is that since we don’t yet have a healthcare “system” in the U.S., we need to build one if we want better outcomes. Maybe this really isn’t bad news. It might be healthy for the U.S. to wrestle with how much emphasis we want to place on prevention, disease treatment, specialist care, primary care, technology etc. It would be very rewarding work to design a system to deliver the agreed upon balance. A national discussion on what to buy in healthcare won’t be easy, but it needs to happen before the actual purchase.