TPBG- Third Party Bypass Grafts- The time has come!!!!

TPBG- Third Party Bypass Grafts- The time has come!!!!

It is time to take Washington out of the equation.

Here is an analogy: Lets just perform a CABG on our present healthcare system, but change the name to TPBG, Third Party Bypass Graft. Leave the diseased portions in place, and just bypass them. The diseased portion will soon cease to function.

Make a route around the diseased portion that is wide open for better patient care and less regulations. Our patients will start moving to the wide open patent system very quickly when they see the medical care is better, easier, and in most cases less expensive.

The past twenty years, we have been trying to treat our present system medically, and all that has happened is that it has gotten sicker. Those that wish to continue to try to treat the problems with letters to Washington, or negotiating contracts with third parties will just be swept up into the diseased portion or evil atherosclerotic plaque. We do not have a pill that will reverse this plaque and defeat the third parties other than to decide to make them irrelevant.

We are overdue for a TPBG. I for one have bypassed the system and am very happy, and will be even happier next year as my practice continues to grow. Ever since my TPBG, I have more time for my patients and my family, and no longer have the morbidity associated with all the third party nonsense. And the beauty of it is, I did not need a knife or a hospital stay for my TPBG. All I needed was a pen and a stamp. I wrote a letter to terminate my third party contracts, put postage on the letter, and sent it away. No morbidity, no referrals, no billing staff, less office staff, and more time to spend with the patients to give better care.

Its like I always hoped I would practice my profession!

1ST 6 month transition to cash practice

January-June 2008 transition to Cash Only + Medicare Solo physician, suburban practice, large HMO penetration. Conversion to cash practice, Medicare, Selfpay and Wellness-Retainer model at affordable market based prices. January and February’s numbers contained some old insurance money and is included in percentages given. Also 2 insurers remained thru part of January due to their contractual terms that I chose not to fight as it only set me back a few weeks. But February and March had little if any old insurance money and was very low compared to January. April-June had Medicare secondary insurance money only, otherwise all revenues were direct from patients.

-------------------------------------------------------------------------------------------------
Comparisons given below are percentages comparing Jan-June 2008 to January-June 2007.

Patient Volume decreased by 41%.
New patients seen decreased by 55%
$ per patient seen Increased by 69%
Revenues remained the same. The revenues dipped in the second quarter. This is due to the majority of my established patients joining my Wellness programs in the first quarter.

------------------------------------------------------------------------------------------------
More Analysis:

$ per patient visit for 1st quarter 2007 was $64.43
$ per patient visit for 1st quarter 2008 was $108.00.



My practice has multiple payment options for patients. These range from selfpay, to Medicare, to Wellness and retainer options. More info on how these options differ can be found by clicking here. The breakdown in patient visits is as follows:



Selfpay 48%

Wellness 23%

Medicare 20%

Old Insurance-Ancillary 7% and dropping

Retainer 2%



The breakdown in % revenues per patient visits is as follows:



Wellness 33%

Selfpay 33%

Old Insurance-Ancillary 21% and dropping

Medicare 11%

Retainer 2%



$ per patient visit is as follows:



Wellness $165.00

Retainer $158.00

Selfpay $87.00

Medicare $61.00



- ------------------------------------------------------------------------------------------------
Further analysis:


Wellness Plan: A good percentage of revenues came in from Wellness Plan fees, which is upfront money. This skewed the numbers higher at the beginning of the year. The numbers, averaging $165 per patient visit, are now coming into the range that I expected and are still almost double the average of selfpay patients. My job is to market my office to new Wellness patients throughout the year. If I do not get these new Wellness patients, the revenues will slow. I am also looking into a monthly payment plan for the Wellness program, which would run between $25-30 a month, instead of a lump sum upfront. This would help with patient budgeting and allow marketing to small businesses. A physician who has already made this system work can be found by clicking here.



Selfpay: averaging $87 per visit. That is $23 more per visit than I received last year, or a relative increase of 35%. Also I have more time open in my schedule to fit in these patients, as I am not seeing the $10 copays or capitated patients.



Medicare: averaging $61 per visit: This is low as it includes office visits for venipuncture, B12 injections etc. Even if this number goes up to $65 per visit, it is still much lower than the selfpay, and a pittance compared to Wellness and Retainer. With Medicare payments from the government expected to drop, continued participation in Medicare is not guaranteed.


Retainer: averaging $158 per visit. This is 45% better than selfpay, but only a small percentage of my practice. As with the Wellness Plan I may allow a monthly or quarterly payment plan. It is really nice to see a retainer patient and know that I can be a doctor and not worry about what everything costs in relation to their treatment.

-----------------------------------------------------------------------------------------------

I have had a good number of patients leave my practice due to the dropping of insurance. Some have been nice about it and understanding, and some have been downright rude and insulting. So be it, I do not take it personally. Each patient may make their own decision. I am still available to anyone who wants my services, they just have to be willing to pay me directly for my services, which are priced at an extremely reasonable rate.The feedback I have received from the patients who have remained has been terrific. While they wish they could pay me less, they have all been happy with the type of non-hurried care they receive. They can get appointments same day. We have time to help them coordinate their care with specialists. All things that were difficult or impossible in the old-insurance driven model.

------------------------------------------------------------------------------------------------


Other Good Effects:



Expenses have gone down.
My medical billing expenses have been slashed by at least 50%.
I have eliminated one medical assistant during my day hours, and went from two to one medical assistants during evening hours. My payroll expenses have been slashed by about 30%.
My supply costs have also decreased by 20%.
I have spent more on marketing the new practice style, but overall my expenses are down about 12% compared to 2007.
For other good effects for my patients please see my blog post of 2-20-2008.

------------------------------------------------------------------------------------------------


My goal is to get to about 1000 patients in my practice, instead of the average of 2500 in my community. If I can get 50% and up in the wellness and retainer plans, my revenues will be higher, and patient care will be much improved. Hopefully the addition of a monthly or quarterly payment option along with the results of marketing my practice will continue the successful transition.

Medisave: A Blend of Government funded healthcare in a privately controlled fund

Medisave: A Blend of Government funded healthcare in a privately controlled fund

Much of today’s debate about healthcare reform revolves around two distinctly differing viewpoints. On one side we have the call for a government takeover of the present system, with new insurance mandates, continued insurance management and regulation, and higher taxes. On the other side we have the call for an end to government regulation, an opening up of the free market, and the end of the insurance industry's undue authority and oppressive control over healthcare processes, without any new taxes.

Is there a way to bring the two sides together?

Let’s look at some numbers:

Estimated population of the United States is 300 million.

Estimated direct government contribution to healthcare spending in 840 billion dollars.

That is about $2,800 a year per person.

Is there a way to spend that money more efficiently?

Here is my proposal:

Individually owned Medisave accounts for all United States citizens from birth.
With no added taxes from the government, the $2,800 can be used to purchase a catastrophic high deductible insurance policy that would also cover the first $500-1,000 per year of preventive coverage for well exams, Pap smears, childhood vaccines, etc.
These Medisave accounts would be individually owned and controlled and could be managed by banks or other brokerage service centers. To cover the costs of the deductible, patients and employers could voluntarily contribute to the accounts. For the unemployed, there could be more charity care and other tax deductible accounts set up. Means testing would also be on the table for those truly in need. Any money remaining in the Medisave accounts at the end of the year would roll over for the following year.
Hopefully money would be saved in these accounts to fully cover any future year deductible. Family members can use a portion of their excess Medisave dollars for other family members or for charity to others in need.

The Medisave accounts would be paid for by the same taxes present today. However these monies would need to be separated from the government’s general fund to avoid having any of the funds spent on other programs. With the accounts controlled by individuals, it would bring an end to government lobbyists and special interests.

Tort reform would also need to be enacted to lower the costs of defensive medicine. A fair system is beyond the scope of this article.

Lets look at the positives of this plan:

1) Lowers employer costs greatly. Employees could get more in salary as a result. Also insurance is fully portable, and not dependent on employment, only upon citizenship. Non-citizens can buy into the plan at much lower costs than today’s insurance premiums.
2) Ends Medicare and Medicaid and all the government regulations and price controls and replaces them with individually controlled and owned policies.
3) No price controls. The free market would set the costs. Competition would open up and be fierce to increase innovation and decrease costs. Look at all the mini-clinics opening up as lower cost alternatives as an example of true free market competition.
4) Citizens can opt out of the plan, but what would be the advantage?
5) If individuals want to buy a Medigap policy for their deductibles, they may buy one on the open market.
6) Insurance companies would stay in business but would have to change they way they operate. They would no longer be in the business of healthcare, but back solely in the business of insurance.

This proposal would cover every United States Citizen and be funded by the government in the form of Medisave withholding deductions from paychecks. This would replace the Medicare withholding. The percentage needed can be calculated by a group of budget economists. It would be budget neutral as no new funds would be needed.

Medicare and Medicaid would end along with the regulations. Patients would have open access to any doctor or health care provider they choose in the free market. Payment would be direct from their Medisave accounts at the time of service or as agreed upon between patient and the doctor or provider. There would be no third party involved to increase costs or intrude upon the doctor-patient relationship. And most importantly, those with medical expertise and genuine interest in our patients' health will once again have absolute control.

An Open Letter from America's Physicians

Dr Steven Horvitz- Reading between the lines: Healthcare Information you can trust!

In the first half of 2008, I have been involved in a grass roots campaign with other doctor's across the nation whose goal is to reform the healthcare system and to restore the doctor-patient relationship to make healthcare once again affordable for all. Written below is a letter that I helped to create along with six other doctors. We are presently acquiring physician signatures so that we can present our thoughts on the problems that face our healthcare system and how we can best solve them.

We presently have over 3,200 physician signatures with more each and every day.

I ask for your opinions on healthcare today and on the letter as it is written. The physician community truly wants to partner with the American public to create and better system.

----------------------------------------------------------------------------------------------------------------

An Open Letter from America's Physicians

Dear Fellow Americans,

For decades the United States has led the world in healthcare. We have enjoyed the finest hospitals, medical schools, research, technology, and resources. Unfortunately, our healthcare system has lost focus to the point where patient well-being is placed after politics, profits, and special interests. Healthcare costs are on the rise and patients have lost their freedom of choice. These trends are hurting our economy and compromising the doctor-patient relationship. As a result, it has become difficult for physicians to deliver the best possible care.

Our heavily fragmented healthcare system has made it very difficult for you, the American public, to get the care you need. As your physicians, we want to partner with you to address the critical defects of the system as outlined below:

• You are paying a lot for healthcare and not receiving enough in return. Your insurance premiums continue to increase while your healthcare options are dwindling. Gatekeepers, insurance networks, and restrictive regulations limit your choice of doctors and your access to care.

• You have been made dependent on complicated and expensive health insurance plans. Employers are forced to take money out of your paycheck to purchase health coverage. If you lose your job, you are left with no safety net and the money you have paid for health coverage vanishes.

• The time you spend with your physician has become remarkably brief due to regulatory hurdles requiring doctors to spend more time on documentation than with you.

We believe the following factors have made our current healthcare system unsustainable:

• The insurance industry's undue authority and oppressive control over healthcare processes

• Excessive and misguided government regulation

• The practice of defensive medicine in response to a harmful and costly legal environment

We, the physicians of the United States, will no longer remain silent. We will not tolerate a healthcare system where those without medical expertise or genuine interest in our patients' health have absolute control. This letter is merely a summary of the most important problems in our current system. We believe that by partnering with the public we can start to demand real change and formulate practical solutions.

We invite you, our patients, friends, neighbors, and employers to unite with us at this important time in the history of healthcare in the United States. Together, we can guarantee our nation a healthier tomorrow.

Please talk to your doctor about this letter and visit http://www.sermo.com/doctor... for more information.

Respectfully,

The Undersigned U.S. Physicians

The Clock is Ticking. My response to a blog post on HealthBeat

The Clock is Ticking. My response to a blog post on HealthBeat.

The link to the above original post on Healthbeat is found next: http://www.healthbeatblog.org/2008/05/the-clock-is-ti.html

I have copied it below with my comments in red.

May 12, 2008
The Clock Is Ticking
After being re-elected in 2004, President Bush began touting an ambitious social policy platform, the so-called "ownership society." Part of this agenda was a strong push for high-deductible health plans (HDHPs) coupled with health savings accounts (HSAs)—tax-free savings accounts to pay for health care expenses.
Like so much else that the Bush Administration attempted (author’s- Niko Karvounis- bias), the ownership society flopped (author’s - Niko Karvounis bias),, in large part because it called for the privatization of Social Security (which failed due to Democratic party disagreements, not to any failure of the Bush administration). With this failure (author’s - Niko Karvounis- bias),, HDHPs and HSAs fell out of the public spotlight. To the casual observer, the question of whether or not health care reform should move in this direction seemed to have been put to rest.
But even though they are no longer in the political spotlight, HDHPs and HSAs are actually thriving—and in fact penetrating our health care system at a relatively brisk rate (The result of free market forces at work). This is problematic (the authors - Niko Karvounis - opinion only). Not only are HDHP/HSA plans poor policy, but their proliferation also weakens the political viability of the health care reform we really need (the authors - Niko Karvounis -opinion only, not a fact).
Here are the numbers: at the end of last month, the Associated Press reported that the number of Americans enrolled in HDHP/HSA plans has nearly doubled (free market forces at work) from 2006 estimates, to around 6 million. Admittedly (by whom?), these plans still have a long way to go before they become a force to be reckoned with. America’s Health Insurance Plans estimate that enrollment in HDHP/HSA plans comprises just 3.4 percent of the private insurance market in the U.S., and in March, Employee Benefit Research Institute (EBRI) estimates that 42 percent of people who have HDHPs and are eligible for HSAs don’t even use the accounts (that is because it is up to the individual, not the government or the the employer. Its called individual responsibility).
Nevertheless, a doubling of enrollees over two years is nothing to scoff at (I agree). And while national rates of enrollment are still meager, the picture’s somewhat different at the state level. The AP reports that in Minnesota, the state with the highest percentage of HDHP enrollees, "about 9.2 percent of the state's total enrollment in private health insurance comes through high-deductible plans. Following closely behind [are] Louisiana, [at] 9 percent and the District of Columbia, [with] 8.7 percent."
State governments are also beginning to turn to HDHPs and HSAs as models for reform. Last week, Georgia passed a law—with the support of Newt Gingrich—that will give insurers $146 million in tax breaks for selling HSA plans (While I like HSA’s, I don’t understand the need for tax breaks to health insurance companies to sell them.). In Indiana, Health Affairs reports that HSAs are being coupled with Medicaid to provide high-deductible health insurance to low-income citizens. (Maybe a way for the Medicaid population to save for their future medical needs, as we do not expect individuals to remain on Medicaid their entire lives. Sort of like Welfare reform signed into law by Bill Clinton.)
In practice, the HSS/HDHP combination makes little sense for families poor enough to qualify for on Medicaid. The $1,100 deductible is more money that most impoverished families have lying around, and the requirement that they contribute 2 percent to 5 percent of their income to the HSA each month ignores the fact that families on Medicaid live paycheck to paycheck and often run out of groceries before the end of the month. (Scare tactic. Please prove that claim) They don’t have a 2 percent to 5 percent cushion to deposit in an HSA. (Not much to disagree on here, but some form of means testing and a way for each individual to save for the future to get off public assistance would be helpful. All income classes would agree with that.)
Yet while Bush was unable to broadly institutionalize HDHPs and HSAs in one stroke Social Security (which failed due to Democratic party disagreements, not to any failure of Bush administration)., it's clear that the two still have made major inroads into our health care system—and into policymakers’ thinking on reform (free market acting on its own!). With so much activity surrounding HDHP/HSA plans, projections for growth are optimistic: the U.S. Treasury Department estimates that there will be 14 million HSA policies in place across the U.S. by 2010.
Despite this healthy forecast, HDHPs and HSAs aren’t the answer to America’s health care problems (again, the author’s – Niko Karvounis -opinion only, not a fact). As I’ve noted in the past, consumer-driven health plans require a lot of out-of-pocket spending (even in the Indiana Medicaid/HSA program, the annual deductible is a not-cheap $1,100). Big expenses at the point of service encourage patients to forego necessary care—including patients with chronic conditions, who often end up needing more costly and extensive catastrophic care down the line. With HDHPs, patients save now, and pay—a lot—later (Instead we have today’s system, where people get everything and then some, and paying little for it, but at much higher premiums, without better long-term medical outcomes. Wouldn’t you rather get a higher paycheck, then insurance you don’t use?)
HDHPs and HSAs also do little for the uninsured, since most families without health insurance are low-income won’t be able to afford health coverage that asks them to pay $4,000 out of pocket before their insurance kicks in (I would like to see true data on this one. Medicaid is available for the lowest income earners. Many of the others are uninsured by choice, not due to income. If affordable coverage was available, they might not be uninsured.) (In 2005, $4,000 was the average HDHP deductible for a family). No wonder EBRI found that in 2007 only 7 percent of people enrolled in HDHP with HSAs were uninsured before they got their current plan, and just 15 percent of those in HDHPs without HSAs had no insurance before enrolling. (And what percent of people today do NOT have insurance? Is it greater than 7-15%? The 2007 estimated population is just over 300 million. If we count 47 million as uninsured that is just over 15%- numbers seem the same to me!)
Asking people to pay more is not the way to expand health insurance to those without it—especially since the higher out-of-pocket spending of HDHPs is often coupled with increasingly expensive premiums. (Not even near as expensive as todays traditional plans) In April, the Minneapolis Star-Tribune reported the story of John Gruber, a 63 year-old man who has an HDHP/HSA plan and who has continually seen his health care costs increase. Even though Gruber’s medical bills have never exceeded his deductible, his insurer Blue Cross Blue Shield upped his monthly premium from $337.50 a month to $470.50 in 2007, a 39 percent increase. His annual deductible also increased from $3,500 in ’04 to $4,100 in ’07. (Why not give the example of the many individuals with insurance that never visit the doctor, have minimal to no healthcare costs. What is the cost savings in premiums and personal healthcare costs to them? What is the profit to the insurer? )
Gruber’s case is not unique: the Star-Tribune quotes Blue Cross Blue Shield as admitting that HDHP premiums are increasing just like those for traditional insurance plans. Patients are paying more out-of-pocket and more in premiums. And don’t count on HSA savings to soften the blow of high health care costs, which have been growing faster than investment returns. (As HSA savings grow year to year, patients will have money saved up for their deductibles, while the catastrophic costs will be covered by their plan. So the problem is ???)
The only folks who can really benefit from HDHPs and HSAs are high-income earners. When you have enough money to pay for your health care expenses, high-deductible plans aren’t a problem; and if you are wealthy, you also have more money to save, making HSAs more useful. (Class warfare at its finest). Finally, HSAs offer a way to permanently shelter you income. Like an IRA, or a 401-k, an HSA gives an employee a chance to squirrel away pre-tax dollars—you don’t pay any income tax on the money the year you put it into the tax shelter.
But with the HSA, the deal is even sweeter: when employees withdraw money from the HSA to cover medical expenses, they still don’t have to pay any taxes on the either the principal or the dividends and capital gains that have compounded over the years. Moreover, "medical expenses" include items often not covered by health insurance including contact lenses, in vitro fertilization, psychoanalysis and dental work. (Coverage for items not covered under todays insurance system- Sounds terrible to me ????? So the problem is??)
As a tax shelter, the HSA has no peer, at least for healthy, wealthy Americans. (No, it works for all Americans regardless of income) Today, a family with cash to spare can sock away up to $5,800 a year, tax-free, sign up for high-deductible policy that will cover catastrophes—and then pay for check-ups, flu shots, mammograms, eye exams and the occasional childhood accident out of a separate account. (That is called choice, and in a free society, choice is to be desired and not taken away)
Why not use the $5,800 in the HSA to cover the medical expenses? Because if you don’t touch the HSA you can carry it over to the next year, contribute another $5,800 and watch the account compound, tax-free, for decades. (And the problem with that is???)
As a gift from the government (actually a remarkably generous present from other,less fortunate taxpayers), the HSA can’t be beat. (How is money that individuals earned and saved, a gift from the government. The government did not work to earn the HSA-money, the individual did. It is not the governments money to take.) A family that tucks $5,800 into an HSA for 30 years, and earns 7 percent a year on their investments, will wind up with a nest egg worth well over half a million dollars—tax free. (And the problem there is??) You can then leave the HSA to a spouse, again without paying taxes. (If your spouse happens to be, say, 20 or 30 years younger than you are, he or she can look forward to continuing the family tradition of contributing to an HSA, and watching it grow, tax-free, for another few decades). (A spouse 20-30 years younger than you. Wow. All I can say is Way to Go!!!!)
A GAO report from last week suggests that families have caught on to the benefits of using HSAs as tax shelters. In 2005 contributions to HSAs totaled $754 million, more than double the $366 million in withdrawals (And the profits of the health insurance companies over that same time period dwarfs the 754 million. Where would you rather have the money saved? In the insurers bank accounts as profits, or in your own tax free medical-health savings account.) This disparity between what people put in and what people take out of HSAs suggests that there’s a certain degree of money hoarding at work, with folks taking advantage of the opportunity to stash big bucks away in a tax-free haven. This has nothing to do with promoting healthcare or a healthier America. (What you call hoarding, others call saving for the future, so as not to have to ask the government or their employer to pay their expenses.)
Given the advantages for the wealthy, it should come as no surprise that taxpayers with HSAs earn almost two-and-a-half times as much as the average American, with an average adjusted gross income of $139,000—compared to $57,000 for all other filers.
Besides the basic injustice of a health care policy that so explicitly favors the rich and the healthy, there’s another reason to be concerned over the high-income bias of HDHPs and HSAs. Maggie has written a lot about how meaningful, system-wide health care reform is going to require a high degree of unity, and she’s right (the author’s - Niko Karvounis - opinion, not fact). But HDHPs and HSAs undermine this unity by giving high-income Americans the opportunity to "check out" of health care reform. (Incorrect assumption. It gives all Americans with HSA’s the ability to put away money for their future healthcare, instead of giving it to insurance companies for profit.)
Think about it. HDHP/HSA plans are a sweet deal for the rich. They pay for care only when they need it—a risk that they can afford thanks to their deep pockets—and they have a new tax shelter to boot. How on Earth are we going to convince the rich to pay higher taxes to fund universal health care if they settle into this cushy situation? (Here is the author’s - Niko Karvounis -biased answer for healthcare reform. Have the rich pay for healthcare for all of America. Is that the American Way???)
Unfortunately, HDHPs and HSAs are indeed becoming the pet policy of high-income earners. According to a March Employee Benefits Research Institute/Commonwealth Fund report, 31 percent of households that held these plans had incomes of $100,000 in 2007—up from 22 percent in 2005. In contrast, just 19 percent of households with high-deductible plans made under $50,000 in 2007, down from 33 percent in 2005. The demographics of HDHP/HSA plans are becoming more uniformly high-income. (Meanwhile, there was little change in income distribution of people enrolled in traditional insurance). (That leaves 50% of households with HSA’s who earn between $50,000 and $100,000- Does not sound uniformly high-income to me!)
HDHPs and HSAs run the risk of dividing our commitment to health care reform by fragmenting interests—and not just for rich people (author’s - Niko Karvounis -opinion, not fact). Like high-income Americans, employers have a vested interest in exploiting HDHPs and HSAs. (Employers exploiting – interesting use of words!) In this case, the appeal lies in the offloading of responsibility. Premiums tend to be lower for HDHP plans than for traditional health insurance, which means that employers contribute less to them. Further, employers are not required to contribute to employees’ HSAs—and in fact there’s a legal limit to how much an employer can contribute if it chooses to do so.
This is good news for employers, who are eager to minimize their health care responsibilities. (I guess it matters whose responsibility healthcare is. I always assumed that healthcare was the responsibility of individuals and families, not employers or government. Why not ask employees if they prefer higher take home salaries or more expensive health insurance?) Indeed, the proportion of U.S. workers covered by employer-based coverage fell from 51.1 percent in 2000 to 48.8 percent in 2006. HDHP/HSA plans might be a happy surprise for the rich, but for employers, they are a long-awaited backdoor exit. So it’s no surprise that firms are increasingly offering HDHPs and HSAs to their employees. The Kaiser Family Foundation reports that in 2003 less than one percent of firms offered HDHP plans with HSAs; in 2007, the share rose to 4.2 percent. Once again, this is not a whopping number, but it’s a rapid increase. (Maybe its due to the high cost of traditional plans.)
Here we have the same problem that surrounds high-income earners: how do you get an interest group to think of the greater good once they catch wind of an immediate alternative that furthers their own self-interest? (Nice rationalization by class warfare! The greater good would be to bring down costs for healthcare, by having individuals assume some individual responsibility for the costs, with government creating a foundation to help those who most need it, not a one size fits all for those who do not!) Can we really expect employers to embrace health care reform that might require mandates or some form of employer-based coverage once they succeed in disengaging from health insurance? Once they’re out of the health care business (Excuse me, but how many employers are in the healthcare business? Does Home Depot sell healthcare? Does your local mom and pop grocery store sell healthcare?), it won’t be easy to pull them back in—even as an intermediary step to universal coverage. (There you have it. Universal coverage. It is not what everyone wants. And to force it by mandating everyone into a single system will just raise costs. Look at the Massachusetts state plan and the cost overruns. Look at all the mandates in Massachusetts. Imagine that on a nationwide scale.)
It’s important to note that neither high-income earners nor employers are officially "out"—at least, not yet. HDHPS and HSAs make up only a tiny part of our system. But as these policies continue to gain ground, the fracturing of health care interests will become more and more of a problem. Wealthy Americans and businesses are two of the most influential lobbies in U.S. politics, let alone health care. If they feel that their self-interest is being served without broader systemic change, then reform is going to be that much more of an uphill battle. (Reform and change are big words being used a lot this election cycle. But the words are not as important as the type of reforms and the type of change that is being proposed)
Ultimately, we should be concerned about HDHPs and HSAs not only because they’re bad policy—which they are—but also because they get in the way of good policy ( The author’s - Niko Karvounis -opinion only- not a fact). And we should get moving on meaningful, universally beneficial health care reform before it’s too late. (I agree on the need for reform of the healthcare system, but not the present author’s vision. We need reform that will bring down costs across the board, by opening up the free market to bring down costs and increase quality. It has worked in all other areas of our economy, it can work in the healthcare system.)
Posted by Niko Karvounis on May 12, 2008.


The remarks appearing in red are by Steven Horvitz, D.O.

Healthcare Persecution

“Things get worse for you only when you try to accommodate your persecutors”

This is a quote from a book I just finished, “The Charm School” by Nelson Demille.

Definition of persecution: Persecution is persistent mistreatment of an individual/group by another group. The most common forms are religious persecution, ethnic persecution, and political persecution, though there is naturally some overlap between these terms.

How does this relate to healthcare and the transition of my practice?

I will call it Healthcare persecution.

And it depends on who are your persecutors and what type of system you are working. I have heard some physicians complain and complain again about how patients are overly demanding and aggressive about their care. They want everything and they want it immediately. These physicians appear to consider patients as their persecutors.

Insurers have persecuted physicians by making managed care contracts more and more one-sided. No one is forcing physicians to sign these contracts. Yet, physicians over the past twenty years have persecuted themselves and their patients by continuing to participate with these managed care organizations.

A result has been that physicians gave up control of healthcare decisions without even blinking. Can anyone order a MRI without prior approval? Try to get a new pharmaceutical covered. Are we truly making decisions or just asking “Mommy May I?” Are our medical decisions being tainted by trying to avoid the managed care bureaucracy? Do you avoid ordering tests or medications that need managed care prior approval? Is that the type of care you went to medical school to learn? Is that the type of healthcare system you enjoy working in?

Our patients no longer feel that we are their advocates and that we do not have their best interests in mind. In today’s managed care environment, Can you blame them? Our patient’s want our help and want it unconditionally. They want the trust back in the doctor-patient relationship. But until we give up delegating healthcare decisions to insurers, we will not get the trust back.

Why did I stop participating with insurers?

“Things get worse for you only when you try to accommodate your persecutors”

Preparing yourselves for the transition away from third parties

Preparing yourselves for the transition away from third parties:

I have been asked by other members of the physician community to write about my practice transition and the different feelings, thoughts and reactions I have had as well as those of my peers, patients and community.

A few necessary items to make the transition are listed below in no particular order:

Courage- I have learned that the path to success is not to always follow the crowd. Watch for patterns and trends and determine what you feel is sustainable and what areas are not.

Thick Skin- There will be many parties that will try to throw mud at you. Face it. A majority of the public does not like change!

Marketing Plan- Be prepared to lose a good portion of your practice. But a good marketing plan outlining the positive and valued aspects of your practice will help you to retain your existing patients while growing your practice with new.

Good communication skills- Goes hand in hand with good marketing. If you or your staff can not communicate the purposes of your transition, it will not succeed.

Savings or a spouse that works- Be prepared for a possible decrease in your revenues. It should increase as patients who desire your new style of practice join you, but how long it will take is not possible to predict.

Ability to stay within a budget- You had better have a firm grasp on your practices finances. Knowing where every dollar goes and being able to determine how much overhead you can cut to keep the practice going and to keep your income flowing is an absolute necessity.

Proactive and visionary- If you wait until everyone else is doing it, you will be left behind.

--------------------------------------------------
Patient’s reactions:

Yelling and Screaming- There have actually been patients who have called up my office yelling and screaming that I no longer work with insurers. They do not understand the concept of a doctor-patient relationship without third party intrusion. I find that these are the patient’s who trust doctors the least.

Abandonment- Some patient’s feel abandoned. Again, you or your staff need to explain to all your practice that they are all still welcome, only that they will be responsible for payments as opposed to insurance.

Entitled- These are the patient’s who feel that they bought a product (insurance plan) that entitles them to free or low priced care.
"I already pay too much for insurance": Some patient’s, no matter how much they like you, feel that healthcare costs too much already by complaining about their insurance premium. It is a difficult concept for patient’s to understand but health insurance and healthcare are two different entities.

Excited and understanding: I like these patients. They understand the issues facing physicians, and they also value our services.

---------------------------------------
Doctor’s in the community:

Inquisitive: I have had responses from other docs such as, "You are doing what?, I wish I had the courage to do that!, and "You’ll end up going back to insurers"

Watching from afar: These same docs are also watching from afar. Many pharmaceutical reps have taken questions from other docs in the community asking how my transition is going.

Eager to steal your patients: Soma, albeit a minority of doctors, actually badmouth me and my new practice style to patients who have transferred out. This is the part I do not understand and is one of the main reasons our profession has been taken over by the big business interests.

Trying to find the courage to be the next to transition: There is one other doctor in my community who has given up insurance and switched to a Concierge practice. In speaking with him, so far he is very happy, and he feels that he has his patients respect.

Respect: Whether other physicians approve or disapprove of my transition, I have earned their respect for making a bold move.
---------------------------------------------------------
My feelings through the transition:

Excitement: It is exciting to start over again. Now I have not totally started over as about 40-50% of my patients have remained in my practice. But it feels good for the ego when you find out that people do value your services and that you are not just another name in the insurance directory.

Pissed off at Insurance lies to patients: I get calls from patients who tell me that the insurance company will not cover testing if it is ordered by a non-participating doctor. Unless the patient is in a managed care setting, this is wrong and disingenuous on the part of the insurance industry. A good article on the above abuses can be found by following this link to an article entitled "The Health Insurance Mafia."

Fear: On the days when I see 6 patients instead of the 25 I would usually average, it can get depressing or fearful. But then the next day comes and I have 20 patients and the fear fades.

Boredom: What do I do with all the free time I have at the office when I am not seeing patients. Well so far, I have had all my paper charts scanned into electronic format, and all the paper and filing cabinets stored in a basement. I am cleaning out some exam rooms and decluttering the other office rooms. I am preparing to give some rooms a new look, new paint and more open airy feel. I have time to journal my thoughts on this transition by use of this blog, and also posting to SERMO, a physicians online community.

Like a doctor again: Imagine you are a primary doctor and you want to send a patient for some tests. You hand them a prescription and send them to your medical assistant who helps the patient schedule the test. No referrals needed. No time consuming bureaucratic waste, a happy patient who feels the office is truly helping them get through the maze of the healthcare system.
More time to spend with family and friends: The best part of the process so far. While I am a physician, I am first a husband, father, friend and neighbor.

Enjoyment of the challenge: Whenever I get bored, I look for a new challenge. I have found it. While my office is low in patient volume, it will increase within a few years, and I will look back on the boredom and wish I had some of it again.

More info on my office can be found on my website at http://www.drhorvitz.com/

Why did I choose to take the risk of alienating patients by refusing to work with insurance?

I often post on Sermo, an online physicians community. I have been asked to comment on parts of my transition to a cash practice:

Why did I choose to take the risk of alienating patients by refusing to work with insurance?

Look closely at the question.

Risk? I look at it as being more risky to my patients, my practice and my profession if I continued to participate with insurers. My job, first and foremost is to my patients. I have mentioned in previous posts and blogs that my father was a family doc. He always put his patients first. “Treat your patients like you would want to be treated, or how you would want your family member treated. Always remember without patients, you have no practice and no career.” I have always practiced by these values. I do not worry about the finances of my practice when I am with a patient. If I do right by my patients and have their trust, there is no need to worry. The practice will do fine!

Alienating patients? I treat patients not their insurance. Every patient I have is an individual, not an insured member, and not a capitated life. If patients choose to leave my practice, it is their choice to leave. I have not discharged one patient from my practice. The patients who have chosen to remain value my practice and the care they receive. Those that do not value my services will go elsewhere. What is the old adage, “You get what you pay for?”

Refusing to work with insurance? I have never worked for insurance. I always work for my patients. Insurance just gets in the way. In the past , how did insurance help me to care for my patients?Oh yea, I remember how! With managing referrrals , preauths, precerts formularies, etc. All of those office tasks were very helpful to my patients and my practice. And the insurance premiums kept going lower and lower, right?????

1st quarter 2008 transition to cash practice

January-March 2008 transition to Cash Only + Medicare Solo physician, suburban practice, large HMO penetration. Conversion to cash practice, Medicare, and Wellness-Retainer model at affordable market based prices. January and February’s numbers contained some old insurance money and is included in percentages given. Also 2 insurers remained thru part of January due to their contractual terms that I chose not to fight as it only set me back a few weeks. But February and March had little if any old insurance money and was very low compared to January.
------------------------------------------------------------------------------------------------- Comparisons given below are percentages comparing Jan-March 2008 to January-March 2007.

Patient Volume decreased by 40%

New patients seen decreased by 50%

$ per patient seen DOUBLED

Revenues increased by 18%
------------------------------------------------------------------------------------------------ More Analysis:

$ per patient visit for 1st quarter 2007 was $63.40

$ per patient visit for 1st quarter 2008 was $128.00

My practice has multiple payment options for patients. These range from selfpay, to Medicare, to Wellness and retainer options. More info on how these options differ can be found by clicking here.

The breakdown is patient visits is as follows:

Selfpay 40%

Wellness 20%

Medicare 20%

Old Insurance-Ancillary 18% and dropping

Retainer 2%

The breakdown in % revenues per patient visits is as follows:

Wellness 35%

Selfpay 29%

OldInsurance-Ancillary 25% and dropping

Medicare 8% and slightly rising as we wait for money to come in and deductibles to be paid.

Retainer 3%

$ per patient visit is as follows:

Wellness $289

Retainer $244

Selfpay $95

Medicare $40 - but waiting on billing-collections-deductibles

Other-ancillary $38 - these are quick 5 minutes visits overseeing a Naturopathic doc.
------------------------------------------------------------------------------------------------ Further analysis: A good percentage of revenues came in from Wellness Plan fees, which is upfront money. This may skew the numbers at the beginning of the year. My job is to market my office to new Wellness patients throughout the year. If I do not get these new Wellness patients, the revenues will slow.

Selfpay averaging $95 per visit. That is $32 more per visit than I received last year, or a relative increase of 33%. Also I have more time open in my schedule to fit in these patients, as I am not seeing the $10 copays or capitated patients.

Medicare averaging $40 per visit. This is skewed as I am waiting for payments to come in. But why should I have to wait? And why should I have to pay a billing specialist to get the money that I earned? Even if this number goes up to $65 per visit , it is still much lower than the selfpay, and a pittance compared to Wellness and Retainer.
-----------------------------------------------------------------------------------------------
I have had a good number of patients leave my practice due to the dropping of insurance. Some have been nice about it and understanding, and some have been downright rude and insulting. So be it, i do not take it personally. Each patient may make their own decision. I am still available to anyone who wants my services, they just have to be willing to pay me directly for my services, which are priced at an extremely reasonable rate.
The feedback I have received from the patients who have remained has been terrific. While they wish they could pay me less, they have all been happy with the type of non-hurried care they recieve. They can get appointments same day. We have time to help them coordinate their care with specialists. All things that were difficult in the old-insurance driven model.
------------------------------------------------------------------------------------------------ Other Good Effects: Expenses have gone down. My medical billing expenses have been slashed by at least 75%. I have eliminated one medical assistant during my day hours, and went from two to one medical assistants during evening hours. I anticipate my payroll expenses to be slashed by about 25-30%. For other good effects for my patients please see my blog post of 2-20-2008.
------------------------------------------------------------------------------------------------ My goal is to get to about 1000 patients in my practice, instead of the average of 2500 in my community. If I can get 50% and up in the wellness and retainer plans, my revenues will be higher, and patient care will be much improved.

I call that a Win-Win!!!!

Leveraged Healthcare

Healthcare in America is changing.

The past ten years the change has not been for the better.

Demand has increased.

Supply has shrunk.

Why is this?

Health insurance has given patients access to physicians for copayments as opposed to true market fees. This is leveraged care at its finest.

The demand for primary care has gone up exponentially. But the respect we receive as physicians has shrunk.

Could the low copays have anything to do with it?

Is this good for our system?

I say No!

The present system will fail soon.

A good analogy is todays housing market and the subprime mortgage debacle. Homeowners paid very little for homes they thought they could afford. But the housing bubble artificially inflated the value of their homes. When the bubble burst, and when interest rates went up, they could no longer afford payments on their mortgage.

Our present healthcare system. Patients pay copays (subprime mortgages) for their healthcare. Healthcare costs are artificially inflated due to large overhead caused by government and insurance mismanagement. Take away the large overhead and insurance intrusion and healthcare (mortgage payments) would again be affordable.

What will happen when the insurers and government can no longer keep up with the artificially high demand?

Will they continue on the present course of price fixing and burdensome regulations that only add to the cost of care?

We need an end to leveraged healthcare.

We need a system that brings the cost of healthcare down.

We need a system that would make health insurance once again insurance, and not prepaid leveraged healthplans.

Taking money out of the system, opening up the free markets, would once again make healthcare more affordable, and cost our patients and the government less. The uninsured would once again be able to afford insurance.

But we need to first remove leveraged payments from our system!

Solutions for our healthcare system

March 9, 2008

For our follow-up to our initial open letter to America, we must continue with our patient focused concerns. We must also show that we can make changes to the present system that will increase affordable access to care for all, and cost our government less. It will also keep the present industries in business, but would necessitate a change in the way they do their business. We are the workforce in healthcare. We have the power to induce change if we remain united in our goals. This followup letter must show our continued unity with a focus on improving our healthcare system for all.

--------------------------------------------------------------------------------------------

We the Physicians of the United States of America, have taken an oath to serve the medical needs of you our patients. As written in our previous letter, the present system makes it more and more difficult. It is wasting billions of dollars a year, increases patient and doctor dissatisfaction, and ruins the needed trust in the doctor patient relationship.

It is time for a change. It is time our healthcare system returned to the principles of our founding fathers, of individual responsibility, where medical decisions are made solely by you and your doctor.

Here are my proposals:

Medicare:

Freeze spending at 2008 levels- this will help our federal government keep costs down and allow Medicare to continue for future generations, while taking up less of our nations GDP.

• Allow doctors to balance bill patients above Medicare set rates. This allows doctors to keep up with their ever increasing overhead. This also allows doctors to remain open to treating Medicare patients. It also opens up Medicare to free market principles, which invariably will keep fees low and quality high.
• Allow secondary medicare insurances to pay more than Medicare if fees rise. These secondary insurers can compete in the free market, which they are very good at.
• End Medicare Advantage plans and the overregulation it causes.
• Means-test Medicare deductibles according to patients tax filings. Higher deductibles for wealthier patients, lower for poorer.
• Make preventative medical care for medicare recipients tax deductible.

Other Third Party Insurances:

• End Third party insurance meddling and determination of care. This third party intrusion into medical care has done the opposite of its intentions while producing profits in the billions. These profits drain the system of much needed resources for medical care. The profits based on ever increasing premiums have made health insurance so unaffordable to many, i.e. 47 million uninsured.
• End Insurance networks and give patients true choice in picking their doctors.
• End Referrals, preauthorizations, pre-certifications, etc.
• End insurance formularies, PBM’s which only serve to restrict and deny medications and increase profits for an unnecessary middleman.
• Stop P4P before it starts.
• Let the market decide the prices- lower cost alternatives will flourish!

End government mandates:

• all people should have equal access to care, but not all people need the same care. Equal care for all means mediocre care for all. One size does not fit all.
• Government should set up system of fair rules and then stay out of it. These rules should be enforced to go after the 1% of doctors, patients, and insurance companies breaking the rules, but leave the other 99% alone.
• Increase individual responsibility.
• Make healthcare insurance and payments tax deductible for individuals as well as employers. Employers should not be mandated to buy insurance for employees. But employers can compete for employees by joining co-ops for health insurance to allow their employees to purchase insurance policies based on individual needs. These policies become portable and individually owned regardless of employment status.

Increase availability of CDA’s and HSA’s.

• This increases individual responsibility while decreasing entitlement attitude towards healthcare. It may even encourage health savings for the future.
• Eliminate bankruptcies that allow discharge of medical debt. This increases individual responsibility and decreases use of our overcrowded emergency rooms. Primary care offices can provide cost effective care for non-emergent conditions.
• End lobbyists power over medical care and decision making. Medical decisions need to be made by doctors-patients PERIOD, and guided by free market principles.

Tort Reform: Defensive medicine cost billions. My local yellow pages has over 130 pages of lawyer ads, and under 40 pages of physician ads. Why the discrepancy?

• The present system allows for jackpot verdicts and is not sustainable. It is driving doctors out of business and into early retirement. A proper system is fair to all and does not increase the cost to all, for the benefit of the few who get jackpot verdicts.
• Propose a medical courts system where we are judged by our peers and not by public sentiment. This will allow for proper damages. It will also force change in the system to deal with medical errors as they occur. The present system does not.

Big Pharma: Your public perception is at the lowest it has ever been, and your stock prices are following. You need to change the way you do business. The free market will help your industry immensely. But todays back door deals with insurance companies and the medication-formulary system does not work for the greater good of our nation. For people without insurance to pay inflated costs to make up for the lower cost to insured patients does not work and is not fair. The system needs to have a level playing field.

• Immediately end DTC advertising.
• Have full transparency in medical studies. Publish all studies, not just those that support your products. No more manipulation of data. If you do, you will be called to task on it! You do not want a continuation of the Vioxx lawsuits.
• Stop dealing with third parties for pricing.
• End pharmaceutical formularies.
• With the cost savings, lower your prices to make your products affordable to all.
  
  
  These are just my thoughts as a solo family physician. I am open to any and all options that we can add or subtract. But we need to focus on one common goal. What is best for our patients and sustainable for our nation.
  
  Steven Horvitz, D.O.
  Founder Institute for Medical Wellness
  
  

February Analysis of Cash Transition

Results of first two months transition to Cash Only practice


February 2008:

1st two months – January-February 2008 transition to Cash Only + Medicare

Solo physician, suburban practice, large HMO penetration.

Conversion to cash practice, Medicare, and Wellness-Retainer model at affordable market based prices.

January and February’s numbers may not indicate future months as some old insurance money came in and is included in percentages given.

Also 2 insurers remained thru part of January due to their contractual terms that I chose not to fight as it only set me back a few weeks.

But February’s old insurance money was very low as compared to January.
---------------------------------------------------------------------------------------------------------
Comparisons given below are percentages comparing Jan-Feb 2007 to January-Feb 2008.

I will try to post further months and quarterly data as it comes in.

Patient Volume decreased by 33% for Jan-Feb 2008

New patients seen decreased by 63% for Jan-Feb 2008

$ per patient seen increased by 204% for Jan-Feb 2008

Revenues increased by 73% for Jan-Feb 2008

Old insurance money should not take me thru further than March 2008. Feb 2008 revenues are consistent with Januarys with much less in old insurance income.

Ok All, Lets here the questions and comments!!

------------------------------------------------------------------------------------

The numbers posted above reflect my suburban solo family practice in a highly penetrated managed care location.

The numbers so far are very encouraging. However they may not indicate the future.
A large part of the initial revenues have been from established patients enrolling in my practices Wellness plans. The enrollment fees start at $200 per year. For more info on the wellness options please click here. In order to sustain the revenues and the increase in $/patient I must continue to enroll patients both new and old in these plans. I hope that March 2008 has equal numbers to the first two months, but April and on need to bring in new patients to the practice. I do intend to start a marketing plan shortly to bring in these new patients. I have had a few so far, and I believe word of mouth will spread to bring in these new patients as it always has in the past.

Why the optimism? The patients who have enrolled so far in the wellness plans have stated to me they are very happy with the product and feel the fees are very fair and reasonable. Also the service we have been able to provide with same day appointments and improved patient advocacy has been very well appreciated by my patients.

What are the problems so far?
The biggest problem so far has been patient’s not understanding that health insurance networks do not dictate who they can see for their medical care. They feel they are breaking rules if they go out of network. They do not understand that they can pay directly for an office visit without using insurance.
Some believe that as an out-of-network physician that they will not have coverage for prescriptions, or other care accessed outside my office if I prescribe it. These are all issues that I have found need a lot of hand holding and teaching of how the system truly works. Once I explain how nothing changes other than my fee, a light goes on in their heads and it becomes a decision of a few extra dollars per visit to see me.

Another problem is all the other doctors in my area who still take their insurance and are thus cheaper per visit than I. But, I have already had half a dozen patients return to my office due to the inability of these other offices to accommodate same day appointments for sick visits.

Other Good Effects:

Expenses have gone down. My medical billing expenses have been slashed by at least 75%.

I have eliminated one medical assistant during my day hours, and went from two to one medical assistant during evening hours. I anticipate my payroll expenses to be slashed by about 25-30%.
For other good effects for my patients please see my blog post of 2-20-2008.

Copy of letter to my patients 2-20-2008

February 20, 2008

We near the end of February, nearly two months into the transition of my practice. Many of my patients, peers, friends and family have asked how the transition is going. So far, so good. The goals I have set for my practice are being met.

Please allow me to list a few of these:

1. Same day appointments- If you are not feeling well and need an appointment, the last thing you need to hear from your doctor’s office is that they can schedule you in three days. That just does not work! We have always offered same or next day appointments, and now if you call our office before noon on a workday, you will be offered a same day appointment. My father was also a family physician in a solo practice. He would always tell me, “Make sure you get patients into your office when they are sick, because if you wait a few days they may not be sick anymore.” I have followed my father’s advice.

2. Longer appointment times- When my office participated with health insurance companies, the large overhead expense forced us to try to see more patients per day. This would often cut into the length of time available per patient. Average appointment time prior to my transition was 12-15 minutes. Now we are scheduling for at least 20-minute appointment times, and longer for Wellness exams and physicals. My goal is that each patient gets the time they need for a full and comprehensive evaluation.

3. Less waiting time- With longer appointment times, I have finally been able to run on schedule. No one is perfect, but I have been doing a much better job of seeing patients at their scheduled appointment times. Another side benefit is less crowded waiting rooms and less time in the waiting room. In fact I am considering canceling some of my magazine subscriptions as no one is finding time to read them.

4. Creating a medical home for my patients- When contracted with health insurance companies my office staff and I would usually spend 4-6 hours per day on bureaucratic paperwork, referrals, precertifications and other health insurance nonsense that should have no place in our healthcare system. Well, no longer!! We now have time to serve as your sounding board to medical advice and treatment rendered by other caregivers and specialists. My office staff also has the time to help with the facilitation and coordination of your healthcare. This includes scheduling diagnostic tests and also referring and scheduling appointments with specialists.

I would like to restate my practice mission statement, as the words below are the standard of care that my office pursues.

To provide outstanding family medical care to our patients with a focus on comprehensive wellness and prevention.

To inform you of healthcare options that your health insurance carrier may not want you to obtain or know about.

To be an advocate for your medical care without regards to the health insurance bureaucracy.

Where patients go to be treated as a person and not as a commodity.

Where patients go to have a Physician who listens carefully and respects what the patient has to say and encourages the patient to say what is on their mind.

To give patients the ability to see their own Doctor and to make appointments without unreasonable waits.

To provide this care with an open mind, and to make your healthcare a team effort between Dr. Horvitz, his office staff, and you, the individual.


I appreciate the trust and confidence that my patients have shown in me. I take my job and my profession very seriously and I strive to treat every patient as I would want to be treated myself, and as I would treat my own family. I will always do my best to make every office visit or phone conversation worthy of your time.

If you have any suggestions or comments on how I can make my practice work better for you, please call or email. I will be happy to hear from you!

Steven Horvitz, D.O.
Founder Institute for Medical Wellness

The Dumbing down of our profession

Thirty years ago our patients paid directly for our services. Those with health insurance sent in claims to their insurance for reimbursement. Health insurance at that time was true insurance. Reimbursement was for expensive medical bills, not for routine care. It covered large and catastrophic medical expenses. It is different today. People are enrolled in health plans that pay for routine medical care and expect that care to be paid for by these plans for a small cost. When physicians willingly contracted with these plans, so began the dumbing down of our noble profession.

Twenty years ago we were called physicians and the people we treated we referred to as our patients, family, friends and neighbors. What are they referred to as today?

· Covered lives
· Health Care Consumer
· Capitated life
· “Name the Insurer” patient
· HMO patient
· PPO patient

With our entry into managed care we gave up the management rights of our profession and handed it over to corporate CEO’s of the health insurance industry. These corporate CEO’s have managed to increase year to year revenues and profits on the backs of physicians, hospitals, patients, and employers. Profits of the health insurance industry is in the billions year to year and continues to increase while payments to those that provide the medical care decreases.

How much money is spent on the insurance infrastructure that does not go into patient care?

If we were to take half of these profits and unneeded infrastructure out of the equation, could we put it towards better use?

Lets see some of what this insurance infrastructure has created by looking at an entire new medical vocabulary.

· Provider
· In-network provider
· Out-of-network provider
· PCP – (primary care provider)
· Physician extenders
· Prescriber
· PBM’s – (Pharmacy Benefit Managers)
· Formularies
· Tier 1, 2 or 3 medications
· Generic equivalent
· Managed Care
· Capitation
· Copay
· Precertification
· Preauthorization
· Insurance referral
· Utilization review
· Quality Assurance
· Incentivize
· Pay for performance
· Third party payer
· Contractual adjustment
· Assignment
· Claims
· Payers
· DRG’s
· Universal Healthcare
· HIPPA

Did any of these words appear in any medical dictionary prior to managed care?

Do you evaluate any patients in your office without using one of the words listed above?

My father was a family doctor prior to managed care. Had he been alive today, but in a twenty year time bubble, he would not understand the mess we have gotten ourselves into. He would say, “Just treat your patient’s well and to the best of your ability, and you will have a good career, a good business and a good reputation in your community.”

How many of our medical offices today are run with my fathers thoughts in mind?

Instead we have reacted to this insurance system quagmire in many ways.

· We try to see more and more patients each day.
· We hire more clerical and billing staff to handle intrusive rules and regulations.
· We go to seminars that attempt to teach us cost-effective healthcare.
· We hire physician extenders.

Does any of the above help with patient care?

Can we really evaluate and treat our patients in the 8-10 minutes we give ourselves?

So we hire medical assistants, billing managers, office managers and health care consultants to help run our practice.

They all help in the day to day operations of our practice, but how much of their time is actually spent with patients, and how much time is spent pushing papers, or on the phone with an insurer, etc?

We go to seminars that tell us to use electronic billing, to buy an electronic medical record, to organize our office to comply with all the insurers and governments rules and regulations. Does any of this help in our evaluations of our patients?

They tell us how to see more patients per day, and how if we only stay open every weekend and five nights a week, that our practices will thrive. But I for one, enjoy my work, but I work to live, not live to work!

Nurse practitioners and physicians assistants are hired to medically evaluate our overflow of patients. Is this a good for our profession? Are we allowing physician extenders to become commonplace in our healthcare system? If we hire them, are we not giving our blessing that they can do our jobs as well as we can? In essence we are hiring our own replacements.

Big business has also reacted to high healthcare costs. Walk in clinics staffed by nurse practitioners and physician assistants are growing quickly. Walmart clinics, and Minute Clinics are in direct competition with family practitioners. They are treating the bread and butter illnesses of our patients, which accounts for a nice percentage of most offices revenues. Do we accept these clinics as inevitable, or do we devise a strategy to compete?

Can we compete?

Do we have the will to save ourselves?

Can we enlist any group to help?

Who will understand the most?

Who needs us the most?

Who is closest to us?

· Lawyers?
· Insurance industry?
· Politicians?
· Hospitals?
· Universities?
· Media?
· Congress?
· President?
· Governor?
· Democratic or Republican party?

Can you find ONE in the list that has any interest in helping our profession get out of this mess and make a better system?

Our patients are the one group that we must get on our side. This will not happen if all we do is complain, without offering solutions for high quality and affordable healthcare. We can abandon all third party payers but we must not abandon our patients. We can and must reform our healthcare system by returning the pricing power to the physician, cutting out the middleman, and return to the primacy/centrality of the doctor-patient relationship. It is a trend we as a profession must set by example.

With the presidential election approaching, and the candidates all proposing fixes to healthcare, setting an example with a unified front must not be a dream, but a reality. All of these have factored into the dumbing down of our profession in our eyes, our patients eyes and the government eyes. If we are to survive as a profession, we need to take control back. We must act to set the rules before we lose control of our profession forever.

Steven Horvitz, D.O.
Founder of The Institute for Medical Wellness

Interesting question from Medicare patient

In my practice I accept no insurance other than Medicare. Today I had a Medicare patient whose family left my practice due to insurance issues. This patient, I shall call Rose, was very happy that I was not only able to give her a same day appointment, but also her boyfriend. She thought the new practice model was wonderful and that she hoped I would start to see a large number of seniors on Medicare.

It struck me that my message of participating with no insurers other than Medicare may not have been fully explained nor comprehended by my patients. Some patients may have left my practice thinking I was only treating Medicare patients. In fact Rose wanted to know whether her family could return to my practice. I needed to have a 5 minute fce to face discussion with Rose and explain my practice was open to patients ages 6 and above. The only caveat being I will bill Medicare but no other insurance for payment. A light then went off in Rose's head and she said she would talk to her family.

I also explained to Rose that I was not hoping for a large Medicare practice, but was very happy with the percentage of Medicare patients that I have. I did not want to be beholden to any insurer, whether government or private. Rose also informed me that her family went to another doctors office and was not happy. This is not good for the other doctor or Rose's family, but it follows my logic of treating patients and not their insurance, of taking the necessary time with each patient, and of not running your office like a cattle mill where the best doctor is the one who sees the most patients for the day. A doctor can see less patients and still earn a good living. I am on pace to see 250 patients this month, which is about 20% off of my amount seen in February 2007. But my revenues so far for the month are 33% higher than in the similar period of 2007.

I gave up capitation checks for Wellness patients. So far the Wellness patients brought in much more revenue than capitation ever did. However I do not know if this will continue throughout the year as my established patients come through the new practice style. I believe I will eventually need to bring in new Wellness patients to the practice to continue the increased revenue. I am preparing a marketing strategy for just that. If anyone reading this blog has any helpful tips for marketing, please speak up.

Steven Horvitz, D.O.

Dr. Steven Horvitz's practice transition

This is a letter I will be posting on my patients blogsite and my website. It gives an idea of what direction I am going with my practice. I also hope to add my thought processes as the transition to a cash practice continues. Hopefully putting these thoughts down in electronic print will help me and other physicians in their quest to get back to the roots of medical care, without the third party interference.



------------------------------------------------------------------------------------------------



When I started my family medical practice in 1998, the majority of patient visits and hence the revenues that came into my office was for sick care. At the time, it was what my patients and the public were demanding and what I was glad to provide. But today, with the baby boomer generation getting older, and healthcare costs skyrocketing, demand has increased for medical programs to help patients stay well.

But physicians today are forced to practice under an outmoded system that rewards frequent, extensive and expensive medical care for the very sick, but does not reward for the teaching and teamwork that goes toward prevention of illness. The government in its wisdom, throws more and more money into this system which gets worse year by year. The tremendous amount of government regulations and insurance industry greed and profits has doomed our healthcare system. The present healthcare scenario will not survive as is. The government can not save it. The health insurance industry can not save it. Only patients and physicians first taking individual responsibility, and then forming a partnership in their medical care can.

In January 2008 I started my transition towards a practice that is more patient centered and patient focused. I terminated my contracts with all health insurers except Medicare. With this practice conversion, I am now able to:
1. Improve access to medical care by offering same and next day appointments.
2. Improve communication with patients through longer appointment times, easier telephone access, and internet communication via email and our new and improved website.
3. Help patients to be better managers of their care via stronger coordination of the healthcare services they obtain outside my office. Many physicians are so busy seeing 30+ patients per day that they do not have the time for this coordination of medical care. In my new practice model, We Do!!

Thus far, I have been able to turn the healthcare system upside down, by engaging patients in this team concept of wellness and prevention. I tell all my patients, “ Put your effort into true health wellness and prevention, and I will treat your illnesses for a discount, without any health insurer or third party interference.” My patients who have teamed with me for their healthcare needs by enrolling in my wellness plans, get discounted fees, usually equal to or less than their insurance copay for all their sick care at my office. I am no longer restrained by health insurer contracts what I can offer and what I can advise. By terminating my relationships with the health insurers, I can again become my patients #1 advocate in their care.

One of the nicest comments I ever received was in 1991, from a fellow medical school student who happened to be a patient in my fathers family medical practice in Philadelphia. He told me the main reason he went to medical school was because of the personal connection and trust he and his family received in their medical care from my father while growing up. This trust shaped this students life and career aspirations. Do people still have this same sense of trust in their doctors today?

Sometimes moving forward is not the answer. Sometimes we need to look backwards, to a system that worked in the past. To a system where you picked your doctor based on quality and trust and not by looking at an insurance directory filled with names of physicians you do not know. My practice will move forward and grow by looking backwards. The basic qualities of the doctor-patient relationship will be emphasized again. My patients will choose my practice for the basic qualities of a true family physician such as expertise, sincerity, personal connections, and trust.

I look forward to 2008 and all the challenges that it brings. I value each and every individual in my practice and hope to continue to offer the best family medical care possible.



Steven Horvitz, D.O.