Healthcare going forward

[KaraBulut]

I believe that you are both partially correct. Being in the "business" one of the first entries in ALL admission docs is insurance information. This even applies to ER. As a one-time uninsured individual, I did not have the leverage of Medicare or insurance to have my costs "adjusted."

Just a few comments-
In the ED, they're not allowed to ask about ability to pay until you've been triaged and assessed. At some facilities, they won't even ask about your insurance until after the physician or nurse practitioner has assessed you. This was part of the Emergency Medical Treatment and Labor Act (EMTALA) of 1986 and has been standard practice for several years.

If you're a private pay patient (which means you have no insurance and aren't eligible for Medicaid), your best option is to call and speak to a financial counselor before elective procedures. Most not-for-profit hospitals would rather offer you a discount- particularly if you can pay a portion upfront - than to write off the account. Depending on where you score on the financial counseling screening, you can usually negotiate a discount and you can usually setup a patient payment contract.

Of course, your best bet is to get insurance- at the very least a bronze plan- which will get you substantial discounts even if your out-of-pocket in the plan is high. Better to pay a $5,000 out of pocket on a discounted bill down from $100,000 than to have a $100,000 bad debt on your credit report.

 

[Kulindahr]

Just a few comments-
In the ED, they're not allowed to ask about ability to pay until you've been triaged and assessed. At some facilities, they won't even ask about your insurance until after the physician or nurse practitioner has assessed you. This was part of the Emergency Medical Treatment and Labor Act (EMTALA) of 1986 and has been standard practice for several years.

If you're a private pay patient (which means you have no insurance and aren't eligible for Medicaid), your best option is to call and speak to a financial counselor before elective procedures. Most not-for-profit hospitals would rather offer you a discount- particularly if you can pay a portion upfront - than to write off the account. Depending on where you score on the financial counseling screening, you can usually negotiate a discount and you can usually setup a patient payment contract.

Of course, your best bet is to get insurance- at the very least a bronze plan- which will get you substantial discounts even if your out-of-pocket in the plan is high. Better to pay a $5,000 out of pocket on a discounted bill down from $100,000 than to have a $100,000 bad debt on your credit report.

We ran into an ER guy who didn't understand this recently. The doc came out to see what was up with a patient loudly in pain, and said he was taking her straight in. The guy at the desk said, "We need her insur--" and that's as far as he got as the doctor called back, "No, you don't." Moments later a nurse told the desk guy she'd tell him when to go to the patient to get any information.

Then another guy tried the same with my mom when she was in pain -- I stuck my head past the curtain and asked for attention, he told me he had to get her information, and I told him whatever, I needed to get attention for my mom.

What was a complete surprise was that three days later a letter showed up from the hospital offering an apology and saying they were going to have a review of priorities for all ER personnel!


As for discounts, yeah -- for the hospital here I just reapply every six months; they're well aware that even people with good insurance need to be able to afford to use it. The absolute minimum for any visit is less than a Starbucks grande -- just five bucks (so I got a bill a while back that with my discount came down to $3.60 and then raised it back to $5).

 

[ballcaphair]

^ I did not say or imply that care would not be provided EVER. I am saying that our coverage is a primary consideration for the billing department. We're not monsters! I'm saying that payment is the foundation of a very top heavy industry. Just now doing the numbers in my head, conservatively, there are 12 care providers on the floor. There are 31 people in business offices. This does not include maintenance and housekeeping. I also do realize from whence my paycheck comes. It comes from you, one way or another.

 

[Kulindahr]

^
I'm not sure of current figures, but the medical group with the town clinic here, before they merged with Adventist Health and got a nice new facility, had six doctors and an equal number of secretaries, plus three nurses and one social worker. Now they have eight doctors, the same number of secretaries as before, plus a dozen nurses I know of, and four medical records people. I'm told that if everyone had the same single insurance company, they could cut the secretaries to two and the medical records people by one. So the number of requires staff would seem to be inflated by 25% due to the tangle of private insurance.

The increase in medical personnel is great, but they still could use at least two more doctors -- it would allow each doctor to see fewer patients and be able to spend more time doing medicine and less doing write-ups. That's why I keep saying that it's essential to increase the country's supply of doctors -- and other medical people; there just aren't enough to do the job right.

 

[frankfrank]

Just a few comments-
In the ED, they're not allowed to ask about ability to pay until you've been triaged and assessed. At some facilities, they won't even ask about your insurance until after the physician or nurse practitioner has assessed you. This was part of the Emergency Medical Treatment and Labor Act (EMTALA) of 1986 and has been standard practice for several years.

Someday I'll actually be able to remember what this law is called. In the past I've only referred to this law that I knew is there, but didn't know or remember its name.

I've said it before...I'm SURE that the Republicans WANT to repeal this law!!! It's a MANDATE on big business, for Christ's sake. They've already been playing their other cards showing they want no regulation at all on banks, ISP's, environmental requirements, etc.

I've never, ever heard anybody else suggest this. Am I the only one out there who's concerned about this?

 

[Benvolio]

Someday I'll actually be able to remember what this law is called. In the past I've only referred to this law that I knew is there, but didn't know or remember its name.

I've said it before...I'm SURE that the Republicans WANT to repeal this law!!! It's a MANDATE on big business, for Christ's sake. They've already been playing their other cards showing they want no regulation at all on banks, ISP's, environmental requirements, etc.

I've never, ever heard anybody else suggest this. Am I the only one out there who's concerned about this?

It is absolutely untrue that Republicans want no laws and regulations, but they want fewer regulations. Democrats always think that if a little regulation is good then total, ever increasing regulation is best.

 

[KaraBulut]

I'm told that if everyone had the same single insurance company, they could cut the secretaries to two and the medical records people by one.

It's not unusual for the insurance specialist/biller to spend hours on hold with insurance companies, particularly if their job is to get preauthorizations. Ironically, it's the specialists who see younger patients who need more staff. Traditional Medicare doesn't requirement preauthorizations and they pay within days of invoicing.

The increase in medical personnel is great, but they still could use at least two more doctors -- it would allow each doctor to see fewer patients and be able to spend more time doing medicine and less doing write-ups. That's why I keep saying that it's essential to increase the country's supply of doctors -- and other medical people; there just aren't enough to do the job right.

Actually, with the exception of primary care physicians and a few specialties, there's plenty of physicians. The issue is how we use them. Physicians only need to see patients who are really sick or for new patient visits. Followups and well visits can be delegated to Nurse Practitioners and Physician Assistants.

A physician doing a procedure on one patient can bill about 10 times what he can bill for a single office visit. Or to put it another way, a cardiologist can be in the hospital doing a heart cath for an hour while his Nurse Practitioner is in the office seeing 4 followup patients during that hour.

 

[Benvolio]

It's not unusual for the insurance specialist/biller to spend hours on hold with insurance companies, particularly if their job is to get preauthorizations. Ironically, it's the specialists who see younger patients who need more staff. Traditional Medicare doesn't requirement preauthorizations and they pay within days of invoicing.


Actually, with the exception of primary care physicians and a few specialties, there's plenty of physicians. The issue is how we use them. Physicians only need to see patients who are really sick or for new patient visits. Followups and well visits can be delegated to Nurse Practitioners and Physician Assistants.

A physician doing a procedure on one patient can bill about 10 times what he can bill for a single office visit. Or to put it another way, a cardiologist can be in the hospital doing a heart cath for an hour while his Nurse Practitioner is in the office seeing 4 followup patients during that hour.

How time consuming are the records the doctor is required to make after ACA.? My primary doctor comes with a young guy with a lapto who makes a record as the visit progresses. But that adds more expense, and the young guy must have at least some training.
The doctors are supposed to keep medical records online, but so far that is a joke. The available records consist of a list of medicines and supplements and dates of visits. Again putting stuff on the website requires help and expense. Worse, if substantive, it would lead to questions, confusion and objections by the patients, which also involves labor and expense.

 

[KaraBulut]

How time consuming are the records the doctor is required to make after ACA.? My primary doctor comes with a young guy with a lapto who makes a record as the visit progresses. But that adds more expense, and the young guy must have at least some training.
The doctors are supposed to keep medical records online, but so far that is a joke. The available records consist of a list of medicines and supplements and dates of visits. Again putting stuff on the website requires help and expense. Worse, if substantive, it would lead to questions, confusion and objections by the patients, which also involves labor and expense.

There's a lot of confusion (and blame) on the ACA about physician documentation. The documentation for Physician Quality Reporting System (PQRS) was passed by the 2006 Congress (3 years before the ACA). And PQRS pays more to the physician for better documentation (which is why they are documenting better).

The difference now is that things are moving out of paper records and into an electronic chart. Some of these systems are better than others. The better ones have the physician dictate notes into the chart verbally and they are transcribed by voice recognition software. Some of the cheaper ones require a lot of typing. In most offices, the medical assistants (technicians who have been through a 1-2 year certification program) do most of the data entry. This allows physicians to see more patients. It's not unusual for a primary care doctor to see 4-8 patients in an hour. Specialists typically see 3-4 patients in an hour.

The goal of the medication list is coordination of care. One of the big problems with Medicare patients is that they have a internist, a cardiologist and other specialists who are all putting them on medications- some of which have interactions, some of which do the same thing. There are now electronic systems that get the information directly from your pharmacy so that you medication list is auto-populated into the record when you arrive. The less expensive systems still require the medical assistant to ask you for a medication list (which the smarter doctors have you fill out at home- where your meds are- and bring with you to the office).

While it's true that adding technology to the physician office has added another step to the office visit, it's not a direct increase in cost to the practice. The nurses, physicians and medical assistants are generating revenue. The big overhead is still the receptionist, the scheduler, the biller and the insurance specialist- they don't generate revenue but they are needed before of the complexity of our insurance system.

 

[ballcaphair]

Kulindahr, frankfrank and all, thank you for your your input. I am too often disheartened to be caring for some of us and their posse who are in the most traumatic situations of their lives; often cost is a client's primary consideration. To me that's just fucked up. Pardon the French.

 

[Kulindahr]

It is absolutely untrue that Republicans want no laws and regulations, but they want fewer regulations. Democrats always think that if a little regulation is good then total, ever increasing regulation is best.

The real problem with regulation in the U.S. isn't that Democrats or anyone want more, it's the way we write regulations. In Europe, regulations give guiding principles that allow regulators to apply them in light of local conditions; in the U.S. regulations are handed down like the law of God with no room for adaptation or adjustment. Another way of looking at it is in Europe regulators are expected to think while in the U.S. they're just expected to wield a club.

 

[gsdx]

To me that's just fucked up. Pardon the French.

That's French which virtually every English-speaking person in the world understands, and I've never heard anyone - not a single person - object to it. (I would give you the French equivalent, but even the French don't like using it.)

 

[Kulindahr]

How time consuming are the records the doctor is required to make after ACA.? My primary doctor comes with a young guy with a lapto who makes a record as the visit progresses. But that adds more expense, and the young guy must have at least some training.
The doctors are supposed to keep medical records online, but so far that is a joke. The available records consist of a list of medicines and supplements and dates of visits. Again putting stuff on the website requires help and expense. Worse, if substantive, it would lead to questions, confusion and objections by the patients, which also involves labor and expense.

At the clinic where I go, "putting stuff on the website" requires a huge amount of expertise: it's called a keystroke.

Yep, once the info is in the form it gets for storage, it takes all of one keystroke to put it on the site where patients can look at it.

 

[Kulindahr]

The goal of the medication list is coordination of care. One of the big problems with Medicare patients is that they have a internist, a cardiologist and other specialists who are all putting them on medications- some of which have interactions, some of which do the same thing. There are now electronic systems that get the information directly from your pharmacy so that you medication list is auto-populated into the record when you arrive. The less expensive systems still require the medical assistant to ask you for a medication list (which the smarter doctors have you fill out at home- where your meds are- and bring with you to the office).

The meds coordination is like a gift from heaven for the elderly. The moment my mom gets a prescription at the clinic, the hospital has the info and it's zapped to her pharmacy. Wen she bounced between two hospitals and a skilled nursing facility recently, the list got updated at every move; all they had to do was access the home hospital's site, select her name from the patient list, point and click. So at each step they could print out for me the current list of what she was getting. So when the community EMT comes by to check up on her, I have a list in case he wants to discuss her meds (though he could get it via my wifi). And when she was in the ER, the list automatically appended to the information for the doctor to view.

It's such an improvement that the wellness coordinator at the medical center says it's health care all by itself, because of the stress reduction for patients in no longer having to make their own list or -- as was common -- bring in all their bottles so a nurse could check the information and write down any they didn't know.

It even got a laugh from my doc recently when I told him my antidepressant didn't seem to be effective any more. He started to ask what other meds I was taking, in order to consider interactions, then laughed at himself and with just two clicks he had my list, another click he was running a program that showed known interactions, and then could type in options for a new antidepressant to check possible interactions. It saved serious time over the tedium of doing the same without having that electronic system!

While it's true that adding technology to the physician office has added another step to the office visit, it's not a direct increase in cost to the practice. The nurses, physicians and medical assistants are generating revenue. The big overhead is still the receptionist, the scheduler, the biller and the insurance specialist- they don't generate revenue but they are needed before of the complexity of our insurance system.

My doc assures me that he thinks that overall the electronic record-keeping actually saves time. He hates the requirement, but as with the medication situation acknowledges that it eliminates some worse drudgery.

 

[Kulindahr]

Kulindahr, frankfrank and all, thank you for your your input. I am too often disheartened to be caring for some of us and their posse who are in the most traumatic situations of their lives; often cost is a client's primary consideration. To me that's just fucked up. Pardon the French.

It is F-ed up. I came close to throwing out one functionary who came to see what my mom's eligibility might be for certain things, who refused to take into consideration anything but the narrow items in her list. Similarly, my doctor explained to me one day that in terms of care for my mom, it's irrelevant to the law whether I'm disabled, everyone living with an elderly person is expected to be brilliant, omnicompetent, and possessed of infinite financial resources or there can be charges of neglect. The whole system is so impersonal, denying basic human dignity and decency, that it's disgusting. And when I had to ask if I could afford to make a doctor's appointment before calling the clinic, it was demeaning.

 

[KaraBulut]

...My doc assures me that he thinks that overall the electronic record-keeping actually saves time. He hates the requirement, but as with the medication situation acknowledges that it eliminates some worse drudgery.

We all hate it- well, all of us who have been in healthcare for a while. The young'uns, they don't know any better.

The reason why hate it is not necessarily because of the electronic format. It has eliminated a lot of redundancy and waste and the patients love that they can get to their records electronically via a patient portal.

The reason that we hate the change is because it's difficult to interact with a keyboard and listen to the patient at the same time. That was something that was happening before everything went electronic, though. Tthe insurance companies say that a patient interaction should be 15 minutes, it's difficult to catch up with a patient that you haven't seen in 6 months in a 15 minute visit. That 15 minute requirement has nothing to do with the ACA or with electronic records.

The practitioners who are mastering the balance between the two are the practitioners who still interact with the patient and then document it... or the physicians who have their medical assistant enter the documentation. In hospitals, we're using nursing assistants to do a lot of the mundane tasks which frees licensed people to do what they're trained to do (something that military hospitals figured out decades ago).

But we're still early in the process- these systems are changing quickly.

 

[thewiz]

How time consuming are the records the doctor is required to make after ACA.? My primary doctor comes with a young guy with a lapto who makes a record as the visit progresses. But that adds more expense, and the young guy must have at least some training.
The doctors are supposed to keep medical records online, but so far that is a joke. The available records consist of a list of medicines and supplements and dates of visits. Again putting stuff on the website requires help and expense. Worse, if substantive, it would lead to questions, confusion and objections by the patients, which also involves labor and expense.

The record keeping and recording are take no longer with the ACA than without. Actually, that was one of the best things that ACA has done -- push us to a simple recording of patient care in a single form and all coordinated electronically.

In the past, ambulance services may arrive at an unconscious person and have no idea what medications they may be taking, medical history, contact information for relatives, etc. When fully developed, an EMS staff can not only access the records but transport to the hospital that they have the patient and be in contact with the doctor treating the patient.

At the hospital or in your doctor's office, everyone uses the same form and the same coding. I can't remember the number of times that I had to fill out the yellow form for BC-BS only to have it rejected because it had been changed to a magenta colored form. I filled that out and was then told it was now a mint green form. When my husband died, it was all done electronically and I was able to connect with my insurance company, the hospital, the doctors, and treating physician in one swoop. If your doctor has to have someone follow him around and do the entry, he must be archaic. My doctor at Johns Hopkins takes the computer from the intake PA, fills everything out as we go, and has already requested my prescription from my selected pharmacy, billed for my co-pay, and I can get a copy of everything at home on my computer through my patient portal.

Finally, if you go to the hospital and they are treating you, everything gets recorded. As past president of a small rural hospital, improper coding and billing areas could subject the hospital to hundreds of thousands in penalties and fines from Medicaid, Medicare, and insurance companies. It is all the same and pretty much "check a box." If people are too stupid to do that, perhaps it is time they retire.

 

[Kulindahr]

We all hate it- well, all of us who have been in healthcare for a while. The young'uns, they don't know any better.

The reason why hate it is not necessarily because of the electronic format. It has eliminated a lot of redundancy and waste and the patients love that they can get to their records electronically via a patient portal.

The reason that we hate the change is because it's difficult to interact with a keyboard and listen to the patient at the same time. That was something that was happening before everything went electronic, though. Tthe insurance companies say that a patient interaction should be 15 minutes, it's difficult to catch up with a patient that you haven't seen in 6 months in a 15 minute visit. That 15 minute requirement has nothing to do with the ACA or with electronic records.

The practitioners who are mastering the balance between the two are the practitioners who still interact with the patient and then document it... or the physicians who have their medical assistant enter the documentation. In hospitals, we're using nursing assistants to do a lot of the mundane tasks which frees licensed people to do what they're trained to do (something that military hospitals figured out decades ago).

But we're still early in the process- these systems are changing quickly.

I've noticed that a observer could tell how important a given visit is by watching who is doing the documenting. For a regular visit, my doc is on the keyboard himself; for something more important, there's an assistant and the doctor dictates; for things that could possibly lead to immediate follow-up such as lab work or hospitalization, there's been a medical student intern.

Your reference to the military reminded me of a comment by one of the senior nurses at the clinic last time I was there, to the effect that they'd learned how to run some things from M*A*S*H reruns.

 

[smokeshadow]

talk about going from bad to worse

http://americablog.com/2017/04/trum...-payments-poor-obamacare-repeal-leverage.html

 

[Kulindahr]

^
As I said -- healthcare going backwards.