In response to GSK verdict

The recent verdict of Glasco Smith Kline really should mean little to me.  After all, I have never taken payment from them.  There might be the occasional lunch so they could pitch their product to me, but I finished residency after the first set of Pharm D laws were passed.  Actually I think that I might have been in medical school when they were passed, but in residency when they went into effect.  What does this mean?  Well, I have never taken a trip to Hawaii on a drug company, I have never gotten a membership at a fancy golf course, nor did I ever accept any money from them.

In the interest of full disclosure, I believe that either Merck or Pfizer paid for my graduation from residency (It has been 7 years, and the program was responsible for details) I have received numerous meals, and pens, and writing tablets.  Did these items influence me?  Maybe, if I am writing a blood pressure medication, and the pen that I was writing with was for a blood pressure medication.  But I would have to believe that it was effective.  I wouldn’t write Norvasc (amlodipine) for a patient in heart failure for example, because they already have problems with swelling.   But most of the time, I didn’t even think about the pen in my handle.  Mostly because it is a stylus that only works on a computer and is black without label.  I rarely use a pen except to sign the few prescriptions that I cannot send electronically.

As for samples, yes I utilize them.  Before the antidepressants started going generic, it was nice to be able to give a patient a two week supply to see if a certain medication was going to work, prior to putting out cash for a high dollar prescription.  Now that there are generics, well that is typically the first choice I write for.  If the generics don’t work, well then I make my next selection with what I can give the patient a sample for, because it is nice to try a medication without spending an ungodly amount, only to find that it doesn’t work.

Now why the verdict means something to me.  With the announcement the Dr Drew Pinsky took at least $275,000 to “provide services for Wellbutrin” (whatever that means) the internet has lit up with claims that this is what physicians do.  They are all on the till for Big Pharma.  Slate online discusses Dr Drew and then implies that most doctors collect checks from Big Pharma.  Lew Rockwell (the founder of the Mises Institute) actually says on his blog “Here is much of the medical profession in a nutshell, since most doctors are in the pay of Big Pharm from medical school onwards.  They get commissions for all those drugs they tell you to buy.”  I guess my check is still coming, since I have yet to see one, yet.

Now it is easy to blow off the likes of Lew Rockwell, since I don’t know if there is a conspiracy that he doesn’t believe (that is my opinion) but his large following is where the problems come in.  He has some of the most rabid of followers and even helps to continue the vaccines cause autism fallacy.  But he is only one of many that are helping to spread the idea that all doctors accept payment from Big Pharma.

Why Dr Drew accepted money from GSK to promote Wellbutrin should even register is beyond me.  He is one of a growing number of charlatans who have traded their respect for media fame.  Dr Drew is worse than most, in that he has also traded on the fame of his patients who are struggling with addiction to create television.  The man let’s face it appears to be a media whore.  I don’t know where in the Hippocratic Oath the statement of except in the case of a television show comes in, but apparently it is there.

I don’t have a problem exposing those that do take commissions, maybe we should be more transparent.  I don’t mind discussing with patients why certain medications would work better for that patient than others.  It is part of my job.  But there are times that the generic is not the best choice for the patient, or maybe there is not a generic equivalent, but this should be a conversation that I have with the patient because it is for the good of the patient, not because some blogger without a medical degree has decided that the whole profession is suspect just because there are a few (alright more than a few, but no where near the majority) corrupt practitioners.  Based on the blogs I have seen on the issue, I have been convicted merely because I hold a medical degree.

Few physicians receive payments from the pharmaceutical companies.  An occasional meal for listening to a drug lecture or spiel but rarely anymore than that.  In fact, I don’t know the last time I accepted a dinner from a drug rep due to preferring to spend my evenings with my children and running them to their activities.  As for those who are paid to promote their drugs, there is supposed to be disclosure for doing so, both in lectures at Continuing Medical Education events.  And believe me, every rep tells me their drug is better than their competitors and all of the generics, I have a medical degree, I think I can figure out that they are in my office to sell their product.

My thoughts on ObamaCare- insurance exchanges

If you are anything like me, your Facebook page, twitter feed and everyone you meet have some opinion on the Supreme Court’s decision on the Affordable Care Act, otherwise known as ObamaCare.  And it is either the best plan ever or the worst decision and Justice Roberts is a traitor to his country, and blah, blah, blah.  Well that was Thursday.

Friday, it was well if we don’t overturn this mess, I am moving to Canada, Australia, Costa Rica, or other English speaking, industrialized nations all with some form of Universal Healthcare or Socialized medicine.  Also countries with a tougher immigration policy than we have, so I am not sure that unless you are super wealthy that is actually an option.

And then there is the stand by the Republican governors to not enact an exchange because they will fight this to the bitter end.  You all know that the exchange was originally a republican idea don’t you?  And probably my favorite part of the bill.  Why?  Well because I own a small business, I have 8 employees, when I started I had two employees, my husband and I, which accounted for a pool of 4 people.  Why does that matter, because when I went to purchase insurance in 2005, I was 7 months pregnant, covered under a policy which I COBRAed through the hospital that I did my residency in.  At $750 a month.  Now I was just out of residency and started my practice on my own, and well $150,000 in debt from medical school, with a new baby on the way.  So I looked for something, and the best I could find that would cover that baby was $1500 a month.  They could not deny me pregnancy coverage as pre-existing at the time, because I live in a states that if I had insurance that previously covered a condition within the last 6 months, there was no pre-existing condition.  However, do NOT ever shop for insurance when 7 months pregnant.

I called 4 insurance agents, and several companies on my own, the best that I could do was to COBRA my current policy ($750 a month) until the baby was born and then start the following month with the new insurance.  Though I actually COBRA for one additional month, because there was some question as to coverage of the brand new baby.  Anyway, this policy I could afford was roughly $400 a month per person in pool, oh and it didn’t cover pregnancy.  And I had an employee who would like to have a baby, so we changed our pool to three, and I covered her on an individual policy, that would cover pregnancy a year after it started.  (Which didn’t work because as it happens, she stopped trying to get pregnant and she had a baby 11 months after the policy started, and ended up on Medicaid for the pregnancy anyway)

Now being as I had insurance for all but my 3rd year of medical school (I had gotten married and could not stay on the plan, and well we couldn’t afford it until my husband started his internship year and it was covered) I could not believe the difference in rates.  I saw what had been taken out of my check at the hospital while I was employed, and it was not that much.  I talked to others as to what they paid working for bigger companies, and the talked the agent, and what the answer was the size of the pool.  My pool was three, and one was diabetic, I was a bigger risk, than those with thousands of employees, who could afford better coverage for less.  But if I got to 5 in the pool, or 10 the rates drop significantly, and then if I have 50 employees, well that is an even better drop.

But with an insurance exchange, here is the deal.  Let’s say your exchange becomes the state for instance.  Larger states might decide to have multiple pools, or smaller states might decide to join into a regional pool, doesn’t matter.  The pool becomes big enough that smaller businesses or the individual could choose a plan that actually works for them within their budget.  If you want to cover pregnancy care, great, here is the plan for you.  I don’t cover it for my employees because it would increase my costs $200 a month per employee, and that includes the two males, who if they become pregnant, I think I would sell their story, me who has had a tubal, and another employee or two that are menopausal.  There was only two of my current employees that would even desire pregnancy, and well at $1600 a month, well it is not even affordable for me to do so.  And as it stood before, they could not even add the coverage as an option because my pool is too small.

While I would have preferred for the market to develop something like an insurance exchange on its own, it is highly unlikely under today’s highly politicized system, it ever would have.  An insurance exchange would allow for those healthier to choose coverage to benefit them better, would allow for people to choose coverage for preventative care.  At least it would ideally, but it would also allow for those with diabetes and other chronic conditions to find a plan that would cover them.  I didn’t say that they all had to cost the same in my world, but prior to ObamaCare finding a plan with a pre-existing condition was impossible without high deductibles, and being astronomically expensive.  And then there was a year of paying for the plan before it would cover any pre-existing condition, so you can understand the frustration for those that tried, and for those that decided against buying insurance.

Like I said, I look at it from a small business who while not required thought that it was right to cover my employees.  I am in healthcare after all.  I actually like this part of the ACA, there is much of the plan that I don’t.  But the opposition to this part, is something that does not make sense, yes the free market should have produced it, but it didn’t.  But this is a natural progression of medicine since the development of Medicare and Medicaid, a natural progression from EMTALA.  I find myself frustrated at both sides on this issue, the surprise that the bill stood, the gloating that this bill is the best thing ever (it is not).  In the last 6 months it was obvious it was going to stand, and if not most of the major components were going to be put in a new bill.  Besides an estimated 60% of the costs in the infrastructure to support the system had already been put into place.  Repealing it would have been of little use.

That is just my two cents worth.  But what do I know, I merely own a small business and see patients everyday.  Do I agree with the plan in whole, no.  But I don’t see the alternative offered by the other side as much different.

To all those graduating residency this month (or close to anyway)

OR What I wished someone told me when I was about to graduate.

Congratulations, welcome to the world of medicine.  Does it seem a little belated?  After all you have been licensed anywhere for 2 to 5 years depending on your specialty, you graduated from medical school and have been officially a doctor for 3 to 6 years, not to mention the 4 years of medical school before that.  So while I grant you it seems a little belated, it is not.  You are now officially on your own.  There is no back up.

For the last 6 months or so you have been counting down the days, the nights on call, weekends on call, or some variation until you were done.  You have taken board exams, presented research and have either had a graduation or are about to have a graduation that is not quite like the ones from medical school and college, but they are still nice, and they are still a big deal.  (I seemed to have forgotten that, and didn’t think to invite my parents to mine.  Whoops)  But you have been counting down the days until your time in now your time and you don’t have to answer to anyone else.

And a funny thing happens, the moment you graduate, you instantly become one of us.  In a way you weren’t before.  Those that are staying close to the program that they graduated from will find it a little more amazing the change from resident to the next morning ATTENDING.  And for the easy stuff it is amazing.  Ear infections, I got that.  Hypertension, well I will use my favorite ACE or beta blocker.  You have bronchitis, and you will be super doctor until “What the heck is that?”  Well that is what you will be thinking, and you will have to stop yourself from saying “I am going to grab my attending to come in here and look at that.”  Because you no longer have an attending you are the attending.  So you will pull out your books or go online to your favorite site and you will figure out to your best opinion what it is.  And if you are right, you will be a hero, and if you are wrong well they will either return and you will try something else, or they will go somewhere else.  You are now the EXPERT.

But don’t think that you are alone.  I made that mistake.  The profession is quite willing to help its fellow physicians, you only have to ask.  Which EMR is best, ask.  Most are more than willing to let you look at their systems and try them out.  You need help with a case in the hospital, you can either officially or unofficially consult one of your colleagues, we love being asked for advice from fellow physicians.  Just don’t ask investment advice, some are really good at it, and some are really bad, best to find a financial advisor on your own.

Make sure you have a good accountant, a good lawyer and a good relationship with a bank.  Seems silly, but those will save you time and again especially if you are starting out on your own.  Rare now a days.  I did it 7 years ago, and it is probably due to the accountant and bank that I am still standing.  You didn’t go to business school, you went to medical school, but school and residency failed to teach you about the business of medicine.  And it is a business.  You want to get an MBA, great idea in a few years.  The first couple you need to work on getting your feet wet in the medical field.  So surround yourself with a great support staff.

Your spouse/significant other who went through all of this with you, was not trained in billing and coding for the most part.  So if they are going to run your business, they need to get trained.  While the motivation is their (It’s their money too) the knowledge may be lacking and you are probably not qualified enough to teach them.  They need to either get some training or hire someone who is trained.

Take time off.  No not the first month, but you cannot go constantly.  It does not serve you and it does not improve the care you provide to your patient.  And all of  your patients are going to get sick and they are all going to be mad that you left them when they were the sickest ever, but that first day back your lobby will be filled because that guy down the street that was covering you, just doesn’t know what they are doing.

And if you are at the program you trained at DO NOT ever in that first year use the line. “When I was a resident…”  Most of the program was just a resident with you, and it loses its meaning when they can come back and say, “You were a resident just last month.”  My fourth year in medical school, I witnessed that from one of the new attending, who went around saying that.  You can say it after everyone who was ever in residency with you has graduated, but until then, they knew you in residency.

And if you use that line don’t follow it with something ridiculous like “I would have liked to get up at 2 am and do an H&P if my attending would have asked me to.”

No you wouldn’t have, and you didn’t like it.  You complained to your fellow resident the next day.  There are crappy things that residents have to do because they are learning and are residents don’t insult them by pretending they aren’t.  And remember you were once a resident, don’t just abuse them because you can.  It doesn’t make you a better doctor among your colleagues.  It just makes you an ass.

This list is far from exhaustive, and I am sure if I had time I could keep going, but I don’t and this blog is getting a little long.  So congratulations on your achievements and hard work.  And welcome to the club.  You membership fees are now due.  (This is only half a joke, you have no idea how expensive it becomes to keep all these groups fees paid)

Allergies and why they matter

As we travel through this allergy season, I am actually having an easier time of it than usual, in what is apparently one of the worst in Southeastern Oklahoma in several years.  Due to the lack of a cold winter, we did not have the period to kill off the normal plants and decrease the load, so I have a great deal of patients in my office complaining of allergy symptoms that in many instances never had.

What exactly are allergies?

According to the Institute of Public Health allergies are defined as “an exaggerated immune response or reaction to substances that are generally not harmful.” 1.   The key to that definition is “generally.”  Because of that word we are aware that there are those that are harmful.  Today more than ever we hear about children who have anaphylactic reactions to foods such as peanuts and nuts.  And yes, I did mean to separate them, because a peanut is technically a member of the legume family and not a nut at all.  Other foods that commonly trigger an allergic reaction include shellfish, eggs, wheat, milk and soy.  These are not always as serious as anaphylaxis but they can be.   Today there is a big attempt to remove milk from the diet, and creates gluten free diet, and unless you are a celiac (allergic to the binding protein in wheat, rye and other common grains) it is found to be a limited benefit in others.  However, limiting your gluten intake may make you feel better, if only due to removing most of the processed food from your diet.  And for those that are allergic to soy, well this diet would cause more problems than not, since many of the replacement foods contain soy.

Another issue that is appearing with soy is that in males in may lead to hypogonadism and infertility.  Now these studies are early and they are still looking closer, but one of the beliefs is that the link may be the result of soy breaking into down into estrogen like compounds and at least temporarily decreasing the sperm count.  Soy can also as I learned in the past week cause anaphylaxis.

 

This picture is actually my son, 30 minutes after his school gave him a large dose of benedryl, which may have been more than the recommended dosage, but with his whole face swelling up, I think it was the better of the two choices.

I myself have food allergies, and hay fever, and everything else that goes with it.  I spent years wearing long sleeves in hot weather, and other ridiculous things to hide arms so that I didn’t have the ridiculous questions about the “track marks” on my arms, and “how I couldn’t hit the vein.”  This is my arm today

This is my arm today.  It actually is relatively under control  Yes you can see the eczema- but there are only a few spots that are terribly red and irritated.  And there is the scratch on the arm.  Must have done that in my sleep.  I am better most days now that I am older and more aware of the damage that I do so I can at least attempt not to scratch.  Those white spaces scarring from the years of scratching.  It makes my skin fairly tough, and hard to take blood, well at least getting through the skin- once through the veins are right there.  But this is enough of an issue that I had to argue with the people at the blood back that they could take my blood.  I mean there is a blood shortage, and you want to not take my blood because of a little scar tissue.  Once the needle is in the vein it all comes out the same

Anyway, other than the unsightly skin, and itchy, watery eyes, and sneezy nose- why do allergies matter?  I mean if those reasons are not enough.  The National Institute of Public health states that most children outgrow their allergies- I am not so sure.  I haven’t outgrown mine yet.  But the Allergy and Asthma Foundation of America estimates that allergies cost $14.5 billion a year.  This includes the direct costs of $1.3 billion for office visits and $11 billion for medication, both prescription and over the counter.  The rest are the indirect costs of missing of work and decreased productivity.  “For adults, allergies (hay fever) is the 5^th leading chronic disease and a major cause of work absenteeism and “presenteeism,” resulting in nearly 4 million missed or lost workdays each year, resulting in a total cost of more than $700 million in total lost productivity.” 2  This makes allergies the 5th leading cause of doctor visits in the United States.

If possible removal of the allergen is recommended for those that suffer from allergies, and those that suffer heavily may benefit from allergy testing and immunotherapy.  At the very least, there might be an improvement in the allergy sufferers quality of life.

 

 

1. “Allergies” A.D.A.M.  Medical Encyclopedia  PUBMed Health  last reviewe October 2011, obtained online at http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001815/(May 6, 2012)

2. Allergy Facts and Figures.  Asthma and Allergy Foundation of America found online at http://www.aafa.org/display.cfm?id=9&sub=30 (May 6, 2012)

 

 

Attitude is everything

Or my self serving whiny post, which does nothing, teaches nothing, and is merely in existence for no other reason than it makes me feel better.

Sometimes I have days like today. Where when I walk into the room, and ask the patient how they are doing, and today is the worst day of their life. If it is one or two, well that is well not ok, but feasible, because at some point you will have the worst day of your life. This morning however, it seemed like it was everyone’s worst day ever. It improved somewhat this afternoon, in that only half of the patients were having their worst day ever, the rest just have multitudes of complaints

In reality, dealing with a couple patients who view everyday as the worse day ever is tiring, a whole morning is exhausting and mind numbing. It is enough to wish for a fully stocked bar in the office. (I said wish, I rarely drink, so much more that a glass or two of wine would make for a bad idea, especially in the middle of the morning, er I mean the afternoon.

Anyway, it is in those patients you realize how important one’s attitude is to their health. Patients who believe that everyday is terrible never seem to be getting better, and while it might be my doctoring skills, I have patients that seem to improve. So that gives me some hope for my skills. I have patients who have their diabetes under control, their blood pressure looks good, and sometimes walk in and say “I am all better.”

And then there is the others. The ones that despite running ALL the possible tests, you still cannot find a reason for their worst day ever, which by the way is worse than their previous visit that was also the worst day ever. They have pain that is a 12 on a 10 point scale where 10 is being caught on fire currently. And then the mention a random surgery were half of the bowels were removed 15 years ago, that they forgot to mention previously. (Not really, pretty sure I would have seen that scar) But there are unmentioned surgeries, medications, and dietary factors that they neglect to mention. Or other doctors that are prescribing medication. (Sometimes the same medication and sometimes one causing side effects that you are treating.)

And then when you do the workup for a condition, you find out that even though their symptoms scream gallstones, they had that removed 5 years ago, and well they didn’t think it was important to mention. I mean after all they no longer have that organ so how can it be the problem? Though I have been told that they didn’t mention it, because they thought that it might have grown back.

Back to the attitude mentioned in the title. Those with an overall positive outlook in life really do seem to heal better, they are healthier. They try, they are not hoping for a magic pill to cure all. And some of them have significant medical diseases. They have the belief that things can get better, that there is something in life worth living for. And they are living life. This does not mean that they don’t have pain. They may, they might not, but they are trying to experience and live. There is some purpose to their lives.

It is not that they don’t have pain in their lives, some have significant tragedies. Death of spouse, child, fighting disease, but they are looking for a greater meaning. They accept that bad things happen, and maybe just maybe these events help you to appreciate the good times. The understand the need to experience everything that life has to offer. And just by seeing them, you feel better. They make your world better just by them being in it.

Attitude is not the end all, cure all. But it is a necessary component to improve one’s life. It helps with healing, it helps to give strength and motivation. It is what makes one successful in life.

My 5010 nightmare- maybe coming to a close?

It has been a little longer than normal since I have posted, and my excuse is that I have been busy.  Not that everyone else hasn’t been, but well work life seems to have been busier than normal.  Previously, I have written blogs about a firewall that was blocking payments and how I could not get through, and that maybe things were finally getting better and they are.  This week we finally got our first check from Medicare for claims since 12/19/2011.  It was for $12.45.  Woohoo, I can finally retire!

I laugh because I actually think that it is hilarious, all this time and work, and complaining about not getting paid for almost 3 months, and when we finally get through, the amount is not quite the amount you expect, because the deductible started over on January 1, and most of the claims on that sheet went to deductible.  All this work and time waiting, listening to the crickets chirp.  Or wishing their were crickets chirping, because it would be something better than silence.

After this time, arguing with the clearing house about their responsibility only to be told to look at their website, which for the longest time said absolutely nothing, and then eventually outdated and somewhat misleading information.

First it was my fault, no, it wasn’t.  I did all the steps, I was told were required for a smooth transition.

Then it was my EMR vendors fault.  Well,. they sent me a new update on January 1, which was downloaded within that week.  Followed by one more update the end of the month.  So maybe slightly- though I did send them a not so nice email as well during my frustration, to which they replied within 10 minutes intially, and then 5 more times within 30 minutes and able to fix the problem by the next morning, and considering it was 5 pm when I sent the first email, I was happy enough with their response.

So that takes me to the end of January, where the clearinghouse has yet to notify me of any problems, or to answer why I have not heard anything in a month from ANYONE (insurances included) to looking at my balance sheet saying “Holy (insert profanity here)!  Why haven’t I gotten paid.  How am I going to make my bills, pay my employees, …”  To only get told I am 1700 in line with a waiting time of 7 and a half hours.  Well that was when their system did not cut me off and hang up on me.  And after all that time I was on hold what was their answer.  “Well you should look at our website daily.”  Well at least they are consistant.  Though they continue to refuse to answer my question “how can you take my money without at least warning me that there is a problem?”  Their answer is still I am sorry for your difficulties and your disatisfaction, but we post things on our website daily.  You should read that.  And when I threaten to leave them, it isn’t any better.  Still with the damn website quote, and does not answer my question, and that I am required to give them 30 days written notice.  Which I will, as soon as I know I am up and running with the new group.  Just have to wait for Medicare approval.

Finally, the clearing house appears to have gotten their job done (only 60 days late, and not willing to take any responsibility).  However, that day Trailblazer crashed.  Nice.  It takes them about 4 or 5 days to get back up and going, and then we get messages that we are not an eligible provider.  Apparently even though Medicare claims that our contract is still good so far this year (we will have to renew this year, it is just not our turn yet) Trailblazer has forgotten to tell us, we need to sign a new form.  OK done.  Now for the new denials- all of our claims are duplicate claims.  Seriously?  It is a wonder, I haven’t gone postal yet.  All of this, filing and refiliing, denials and everything else to get the anti-climatic check of $12.45.  Awesome

However, I have gotten in contact with some great people that have helped.  Apparently, I helped my professional organization find out there was a problem, and they narrowed it down to Trailblazer having the biggest issues.  They determined that the physicians in Oklahoma and Texas appeared to be having the biggest problems.  Talking to some billers across the country, those using a clearing house seemed to have more problems than those that didn’t.  So guess what?  I had both issues.

And in the middle of this all, apparently Trailblazer is installing new software to help fix the problem (which apparently started last year)  I have heard from my congressman and Senator and one state Senator, but since things are improving we are hesitant to have them do anything.  Because there is no desire to cause further stalling on the issue, especially now that payments (did I mention $12.45) are finally slowly coming in.

As for my relationship with my clearinghouse- Well it will come to an end when I receive approval from Medicare for my new billing company to file how the prefer to do it.  After 6 years, I think it is time, and my loyalty apparently means little to them.  But I did let my colleagues in the area know that their clearinghouse was at least partially responsible for them not getting paid.  Helpful website indeed.

But I had good news on Thursday, I finally had enough money to catch up all of my bills.  I didn’t have to take out a loan.  I still didn’t get to take home a paycheck, nor did my husband, but maybe next month.  It is really sad that Wednesday, I saw 40 patients, and my hubby saw 33 patients in the office and 7 in the hospital, and we were longing for the days that we saw 17 and took home a paycheck.  But maybe as things start rolling, we will be able to see some of what we have worked for.  I hope so, because I didn’t go to medical school hoping to support 6 other people and not get paid myself  (we are now down 2 employees, after one dying at the beginning of the month, and the other being fired).

Anyway, as the computer glitches resolve, we will move foward.  Looking ahead to the crashes and glitches that will come with the conversion to ICD-10.  Oh happy days ahead/

Dear Center for Medicare and Medicaid Services

This is an email that I would send to the Center for Medicare and Medicaid Services, but since they don’t have an email address for themselves, unless I want to report fraud on either myself or another, well I will have to make do.

 

Dear CMS-

I would say that you don’t know who I am, but you have used my picture for the last year advertising your EHR Incentive program as the first clinic to receive the Incentive Bonus from Medicaid.  So you must at least have an idea of who I am.  That being said, you probably don’t care, but at least you know that I have tried to play by your rules in order to win that honor.

Couple that with the calls a couple times a month from the Office of the Inspector General looking for the physician whom we  agreed to become custodian of record for, well you have talked to at the very least my office staff.  And we have given you all of the information we have.  OR have at least indicated just let us know what you want, we believe that she left the country, given you the email addresses we have, but we don’t have what you are looking for.  Well other than the patients version of what she did.  But otherwise you have not had many dealings with me.

I have a practice of 45% Medicaid and 25% Medicare.  So all together about 70% of my practice is receiving “insurance” from your office.  Over the past year, we have done all of your recommendations for 5010 conversion, and per you and our systems passed them all.  We have performed the required updates, installed the needed hardware, software, implemented the required training, all that you have indicated as necessary.  So based on those, we were ready for the conversion January 1, despite the delay to March 1, 2012.  However, you decided to implement the conversion on December 19, 2011 and installed a firewall.  This firewall blocking all new claims from going through.  We didn’t notice it right away, due to a 2 week to 45 days delay from date filed to date paid.  So we didn’t notice.  Add to that the notification that claims would be delayed about 2 weeks, well it took a little while.  25% is a large chunk of income, but it would have been ok, for a short period of time.

On December 28, the firewall went up for Medicaid.  Again there was a slight delay in noticing, since the turn around is two weeks, plus we were told that there would be a two week delay.  However, this was somewhat more painful.  Added to that the insurance companies have all installed required firewalls, however, after three weeks, we are finally through and getting paid.  So we are receiving payment for 30% of the work that we do.  That does not even cover my staff or overhead.

My understanding is that I am not alone in this problem.  It is neither EHR vendor specific nor clearinghouse specific.  The only constant is that they are plans paid for under your umbrella, Medicare, Medicaid and Tricare.  And one message received was that I was fortunate, at least my problems only started in mid-December, not early November like some physicians.  Whatever.  I have not taken a paycheck since the middle of December.  That is no paycheck for either my husband (also a physician) and me.  Still had to make payroll for the staff of eight that I employ.  Well currently seven, due to a recent death.  But even she received a paycheck this last pay period.  So I have had enough to pay 8 people, well up until this week.  This week, I had to pay some staff out of personal accounts.  So now, not only am I working for free, I am paying for the privilege to deal with government regulations and bureaucracy.

Oh and did I mention that I experienced the privilege of an audit by Oklahoma Medicaid during this time, which other than a few minor problems, I passed.  One of those being something that I have no control over, being specialists not sending their consult notes to go with the referral that they got paid for, but somehow that is my deficiency, DESPITE CALLING AND ASKING FOR A NOTE!!

So anyway back to the point of this message that you will neither read, nor receive, but maybe someone out there will hear me.  I paid for the pleasure of working last week, PERSONALLY!!  And I wonder why I constantly have a headache, and the gnawing of an ulcer in my belly.  I own my clinic, and am personally responsible for the debt to go into business.  I don’t have a big corporation that can afford a short period of time to cover not being paid.  My clinic sees 68 patients on average a day, so I should not have a negative balance sheet, but I do because for 70% of them, I have not seen a dime since December 28, maybe a few more due to the small amount of TriCare that I also see.

I know that I am not the only one who is experiencing this, since this week we were 2017 in line when calling to see where the problem was.  (We were 1700 last week, and that ended with 7 and a half hours on hold, only to be told to check online for solutions, WHICH WERE NOT THERE!!!)

I scraped enough for payroll this week.  In two weeks, I may be able to do it again, even without payment.  But after that I will be done, I will have no choice but to close my doors.  I understand the theory that you should love what you are doing so much that you would do it for free, but I did that the first 18 months in practice, and 6 months in 2010, and an occasional pay period here and there.  But I cannot afford to do that for much longer.  And I definitely cannot afford to do it and pay to do so.  Currently I have $120,000 in Medicaid Accounts Receivable since December 28, and another $60,000 in Medicare. (that is not what I will receive, only what I am billing)  And if by some miracle that were to come through tomorrow, I now have back bills and creditors who would also like to be paid, so even if you were to fix it tomorrow, I will be working for free until May or June.  So my husband will have to spend more time away from his boys, and work more shifts in the ER so we will survive.

I know to some, this is what I deserve being a greedy doctor, though I have yet to make over $100,000 personally since graduating residency.  (My declared income is higher only because of my husband working in the Emergency Room)  I have bills to pay, and cannot afford to continue floating the payroll for the clinic.  So I am asking CMS to look at their firewall, and attempt to fix it, or the looming doctor crises will come in about 2 or 3 months instead of the 3-5 years that is currently anticipated.

 

P.S. If this is your plan to save Medicare, it is a really crappy thing to do.  You should look closer at where your biggest incidences of fraud occur, and not cause those who are playing by the rules to become financially ruined.

CMS blocks payments to providers through firewall

The Centers for Medicare and Medicaid services have found a way to save money.  They simply installed a firewall which blocked claims submission from providers who have complied with the 5010 conversion by January 1, 2012, which was their initial deadline.  And the best part, most providers did not realize the problem until the end of January.  In what has been one of the worst weeks in my life at the office, we received a phone call on Tuesday, from another office who used the same EHR and the same interface processing claims asking if we had been paid this month from either Medicare or Medicaid.  The answer was, yes.  Well initially it was yes.  Followed by “Well only by Medicaid.”  Followed by, “Well outside of our medical home payment about $18.22.”

WHAT!

Throughout this month, I have been watching the income come in.  And until about the middle of the month, it was about the same as last year, maybe even a little more.  And while I was not thrilled with that considering there was more patients 45 days before than there had been a year ago, money was still coming in.  And we had already found that there was a problem with a glitch in our billing and were attempting to locate it.  So I was already not taking a paycheck this month.  So at least my salary was not affecting the outgoing.

However, as the month went on, that number seemed to not change the way that it was supposed to.  Well, we are looking for it on the one hand, but last Thursday, we underwent an audit from Medicaid, so much of our effort went to preparing for that.  Making sure that all of our i’s were dotted and our t’s were crossed.  Knowing that no matter what they would find something wrong.  Realizing too late, that after our last COLA inspection, our CLIA certificate seemed to not be put back in the same place, and was currently MIA.  Which is not great news, especially since a computer glitch at CLIA has not allowed them to send new certificates out, and we are still waiting today for the request submitted two weeks ago.

So anyway, while the numbers were concerning, they were not in the front of our mind, until Tuesday.  When a call partner called, and we looked.  And then discovered.  We had not heard anything from our clearing house all month regarding claims.  So we examined further, and that $18.22 was from Medicaid secondary payment which was submitted to Medicare prior to January 1.

So we called our interface to find out what happened.  “You are currently 1,746 in line.  Approximate wait time is 7 hours 32 minutes.  Did you know that you can check wait times online visit www….”

Well that sounds, uh promising.  After utilizing a phone line for the entire day, we found out, that there was the problem, they were contacting our EHR, and no they don’t know when it will be fixed.  That was tuesday.

Wednesday, we found out that it was not just our EHR having problems.  It was multiple EHRs.  And we started looking for a new way.  We had recently hired a new billing company, who was in the process of creating tunnels and whatever else is required for them to extract our data over the internet and bill for us, would they be able to take our Medicaid claims and submit them an alternative way?  The answer was maybe, if we can figure out how to extract them from the mess, we currently were in.  (Then tragedy struck our office Wednesday afternoon, and to be honest, we just tried to finish our day)

Thursday morning, numb and still in shock, we checked by on the Gateway.  Still no payment, but there was something that had not been there in a month.  A screen of rejections.  We don’t know if that is a good sign or not, but it was something new.  Still no payment.  But a new screen.  And the interface was still working on the problem.  (However, this did not prevent them from drafting my account for payment earlier in the month)

Finally, Friday morning came some answers.  Calls to Medicaid to make sure that we would not get hit with a penalty for attempting to file claims multiple ways, which received a probably not, also had some news.  Apparently the day before, they received 18 electronic batches through interfaces.  While they did not know if they were ours, they said it was promising only because they had not received anything the entire month of January.  Nice.  And you could not have said anything to your providers?

And Friday morning, also provided word from our clearing house.  Apparently the 5010 conversion had caused this.  Despite providers, software vendors and electronic interfaces having had successful tests from the previous year, January 1, conversion did not go as planned.  A firewall at CMS enacted for this event, did not recognized claims that were in compliance or not.  It did not recognize NPI numbers, ICD-9 codes, or CLIA numbers.  In an essence, those who complied with the rules by the initial deadline were penalized and just not paid.  This included all federal government programs Medicare, Medicaid, and Tricare.  Well actually Tricare was worse, their firewall had been blocking claims since November.  And our situation could have been worse, there were Medicare providers who had not been paid since November.  And this is for those that comply with their rules.

Unfortunately for me, 45% of my income is from Medicaid, 20% from Medicare, and Tricare <1%.  So you can imagine what this is doing to us.  The only thing good with regards to Medicare is that we collected their deductibles up front, so we did get some of that.  Though there were also glitches with Blue Cross Blue Shield which is our 3rd biggest payor, which has a percentage close to that of Medicare.  So I guess that I am lucky that I am sitting at half of the number that I should be.  Next month figures to be worse, when you consider a 45 day wait time for Medicare on average.  If we can get claims through under Medicaid, I should get paid in as quick as a week after submission.

So the month of January, I have worked for free.  February, I will also not be taking home a paycheck, and I imagine it will be close to May, since March and April will require me to catch up on bills not paid this month due to the CMS firewall.  Which means more shifts in the ER for the hubby, so that we can survive at home, since my bills won’t stop.

So those of you who think physicians are just greedy, and should be willing to take a 27% cut in pay from Medicare (which would result in similar cuts from other insurances) consider this.  My overhead does not decrease, it increases.  I still have to pay my staff, rent, electric, water, etc.  And following this incident for being in compliance… it is no wonder that physicians don’t trust CMS.  I have not committed fraud, and have played by the rules.  But situations like this sometimes makes you wonder why you bother.

So before any of you call your physician greedy or just in it for the money, think about this.  Those that are self employed didn’t get paid this last month at all, and will probably not get paid this month (take home pay).  The fact that they don’t trust CMS results from issues such as this.  And that is not even looking at the cluster that is ObamaCare.  So I worked last month seeing patients for free, will next month as well.  Sometimes you have to wonder if that time wouldn’t have been spent better elsewhere.

So I guess CMS has come up with an ingenious plan to save money.  Just block physician claims from going through at all.  That way, their money is able to stay in their account and draw interest, and well unless providers close their doors overnight, their patients are still being seen at least temporarily.  So if you look at the numbers for January for CMS, I am sure they look the best in a decade.  Thanks CMS.

Obesity epidemic and school lunch standards

About 5 days ago, the USDA set guidelines for healthier school meals.  As a physician, I should get totally excited about that, but upon hearing the full story, I think my reaction is more of a what?  As the obesity epidemic reaches dramatic proportions, our children are not left out.  According to the American Academy of Children and Adolescent Psychiatry 16- 33% of children are obese.  This is a startling statistic but based on my patient population, I would estimate the number is closer to the 33% rather than the 16%.  But then again, I live in southeastern Oklahoma, and see a patient population of 45% Medicaid.  That is their primary insurance, it does not include those who qualify for Medicaid as a secondary insurance.  During medical school, I never imagined that I would be consulted by parents regarding their underweight child, only to determine he is the only one in the family that is on the growth chart and of a normal weight with respect to his height.  Or the number of children dragged in by their parents sure that their child has a thyroid problem, because it could not be that the only exercise the child gets is to get up off the couch to go to the bathroom between commercials, or that a large pizza is considered a serving size for them.  So I understand that obesity is a problem in our youth.  And I would applaud any efforts to help curb it, should those efforts actually make sense.

This is not an argument for whether I want to subsidize school lunches, food stamps or other government agencies.  These programs are in place, and for the moment, if we are to continue with them at least let their policies make sense.

Per the report found in Reuters  “The guidelines double the amounts of fruits and vegetables in school lunches and boost offerings of whole grain-rich foods. The new standards set maximums for calories and cut sodium and trans fat, a contributor to high cholesterol levels.”  And while I fully understand that, and the attempts to offer only fat-free or low-fat milk, and assure that proper portion sizes are given to children, I doubt that this is even possible to enforce much less implement.

My experience with cafeteria workers is that few if any realize what a proper serving size for an adult, much less a child.  I spend quite a bit counseling patients that serving sizes are roughly the size of their hand (since it is much easier to grasp and compare than carrying around a scale).  And currently, I have heard of schools allowing 2nd and 3rd servings to children.  With few exceptions there is not a child that ever needs a third tray of food.  (Those rare exceptions of underweight and active children this applies to the population that are not at that end of the spectrum)

Not to mention, the black market aspects that could foreseeable pop up.  Who is going to keep kids from bringing food from home?  I know it is being attempted in Chicago, but I remember sneaking brownies and gum into the classroom, where we weren’t allowed to eat as a child.  How are you going to determine if this is food from home, or from the cafeteria itself.

And the biggest reason that this will not work, the original proposal was blocked because potatoes were not initially allowed as a vegetable.  And pizza was also not allowed as a vegetable.  I like french fries and pizza as much as the next person, but let’s be real, health food they are not.  When the food manufacturers selling the food are allowed to dictate what constitutes health foods and what does not, there is a problem.  What child is going to pick an apple over french fries?  Will the school lunch still be able to meet the nutritional standards?  How precisely would those two be considered nutritional equivalents?

As a physician, I spend a lot of time talking to new diabetics and obese patients about their diets, and well pasta and potatoes appear to be the biggest contributors to the caloric intake.  It is what they learned from the USDA and their food pyramid.  The very same organization setting these standards.   The same organization which allowed the lobbyists to dictate the new standards.  And at what cost?

While I agree we have to start somewhere with educating the public and attempting to change the dietary habits of children before the suffer the health effects of obesity, including early onset Type 2 diabetes, hypertension, and high cholesterol, I don’t see this actually being effective.  Substituting whole wheat for white flour in pizza and spaghetti, while it looks like a wonderful idea on paper, may instead be thrown away in favor of other offering either by the school, or an entrepreneurial student.  And while I am in full support of the potential economic lesson this might lead to, it most likely will do little to help.  Nationwide standards have not helped to improve our education system, and without getting input from local officials and parents, I doubt that this will be much different.

Had change been truly desired in the school lunch program, input would have come from the parents, teachers, physicians, dietitians rather than the food industry who would have seen their potential profits cut.  The making of a pizza a vegetable merely because of its tomato paste (which is incorrect, since most use sauce which has a lesser concentration of tomatoes and tastes better) shows just what kind of answers we get from Washington.

When did my career become a secret?

A couple of days ago I noticed something. When people ask me where I work, I don’t usually introduce myself as a doctor.  It was one thing, when buying a car, that I would off-handedly say, “I work at the hospital.”  You are always told adding Dr to your name adds zeros to every purchase, buying a car, building a clinic, buying a house.  Anyway, in purchasing, you just don’t do it.

However, this time it was different.  I was eating dinner with my children at the Olive Garden, when the waiter asked what I did for a living.

I was wearing scrubs, so the question was initially, “So did you work all day.”

“Yes.”

“So what do you do?”

It was not the waiters fault, he was perfectly hospitable, taking care that our table had drinks and attention that anyone would appreciate.  We talked about the iPad 2, since I happened to have both children’s and mine with me.  And if I thought it would be a good deal to buy one, and if we liked ours.  All perfectly pleasant.  It was only when he came over during a discussion with my oldest, as to why I could not donate blood at his school’s blood drive the next day.  (Previous years, I have, but this year it was on a Wednesday, and most Wednesdays I barely have time for lunch much less time to drive 30 minutes to his school, donate blood, and return to work)  So I pulled up my schedule on the iPad, and showed him how full it was.  Still not overly impressed, he said, what about after work?  At that point, I promised him, if by some miracle of miracles, I were to finish by 4 pm, I would donate blood.  However, since I have yet to get out of the office by 530pm on a Wednesday in about 8 months, well it probably was not going to happen.  And this is when the above conversation happened.

I don’t know why I stuttered.  I am not really ashamed of what I do.  Obviously I would not be blogging about it online if I were.  But stutter I did, as I admitted that I was a physician.  Admitted, is this what the once noble profession I dreamed of being as a child came too?  Or maybe it was that I was caught off guard, since it was an early dinner due to having to leave work early in the afternoon to take my youngest to speech, and then kill time between therapy and a skate party.  And maybe that I was worried I would have to explain.

I spend a lot of my day explaining things.  Why I don’t take call, why I don’t go to the hospital regularly, why I have no desire to work in the ER, why I leave early on Tuesday and don’t see patients on Thursday.  And maybe that was the reason.  However, he did not ask for explanations, he actually was reassuring that my career was not equivalent to that of a drug dealer, even though some days, I think that is what I have become, at least in the eyes of some patients.

Maybe I spend too much time online, reading the terrible things people say about doctors, how they make too much money, they rush in and out of rooms too fast, they take too much time to get to their room, that they just don’t care.

I heard a joke once in training that the person who yells out first “Is there a doctor here?” is probably a physician themselves.  And sometimes, I wonder if that is true.  The days, weeks, months, years of fighting public perception as a money hungry individual willing to throw their patient under the bus for a dollar on one side, and the fighting for the dollars rightfully earned trying to provide the patient care that they deserve may have worn us down.  The time spent fighting against liability claims and fear of lawsuits despite no wrong doing, maybe those have worn us down as a profession.  The stories of physicians who have stopped to help someone on the side of the road and despite no wrong doing receiving a lawsuit for a bad outcome.  Maybe that is why we no longer stand up and say I am a doctor.  Or maybe, I just I don’t want to be chased through the grocery store to look at a mole.

And in my case, where my husband and I made the choice where he would take my call, so that one of us could be at home at night with our children, maybe I just didn’t want to explain one more time, why I don’t go to the hospital.  It is not that I can’t, it was that I put my kids before my career.  It is the years spent justifying why I don’t do shifts in the ER like my husband.  It is the time spent alone, at night, wondering if I made the right choice.  Did I do what was best for my patient?  Did I make a difference for the better?  Or what am I missing on that patient?

For the most part, I love my job.  I like that I am in most of my patients’ lives.  In many instances, after they get a recommendation from a specialist, they come back and ask me what I think they should do.  Or if they could have a second opinion, not necessarily that they disagree with the first, but that it is a major decision and they would like to have another perspective.  I don’t make as much in my clinic, as my husband makes doing his shifts in the ER.  I see the reports as to doctors not choosing primary care residencies, and I understand.  The money is not as good, and most of us graduate with a large amount of debt.  And you have to spend a large amount of time fighting, fighting insurance companies, fighting for payments, and watching the general population equate your training with that of a midlevel.  Even though you have twice as much training, 4 times as much debt, and way more liability.  And then at the end of the day, you notice the pile of paperwork- not visit notes, but other paperwork.  Prior authorizations, home health messages, home health certifications/re-certifications, various forms for patients regarding why they cannot work, disability questionnaires, and random notes that the patient wanted you to write for them yesterday.  Add to that orders that the specialist decides that they want done, but don’t want to obtain the prior authorization themselves, despite having the pertinent data needed to get the test approved, and yet they don’t send it to you.  So I understand why students are not choosing a career in primary care.

And maybe it is just a combination of all of those reasons that I don’t introduce myself as doctor out in public.  At maybe, just maybe that is why I stutter when asked what I do for a living.