The final rules for the formation and procedures related to health exchanges are rolling in. Doing research into laws gives me a head ache.
Are you ready to start reviewing contracts presented by Qualified Health Programs (QHPS)? Do you even have a clue what a health exchange is going to look or act like?
There remains latitude in how the plans can be presented, advertised and contracted with health care providers. A final ruling that will present a challenge to providers of health care involves the 90 day grace period the insured receive associated with non-payment of health insurance premiums.
Under the final ruling QHP’s are required to pay for services provided up to 30 days after the commencement of a non-payment. To protect the interests of the QHP’s and of the insured services provided in the 31st -90th day could be held and marked as pending. If the insured fails to bring his account to full status by the 90th day of the grace period his policy may be terminated. At that point all pending claims can be denied.
This scenario only applies to those individual insured who received advance payment of the premium tax credit. It should also be noted that QHP’s are given the option to not pay for services provided between the 30th-90th day of non-payment. If they are moved by the largeness of their heart they can pay all 90 days of claims. Raise your hands if you think this is going to happen.
This ruling leaves providers open to potential debt and fees associated with collecting those debts.
It also raises questions in my mind.
When a provider is notified that all payments are pending, can a provider require cash payment in advance prior to providing services? What about elective procedures? Can the provider decline to provide non-essential services? I don’t have the answer to these questions.
If you have any advice or expertise it would be appreciated.
Below is a quotation from the federal register of 5/27/2012.
You can also follow this link and look for page 18394
“Comment: Several commenters requested clarification regarding how the grace period for non-payment of premiums would work for individuals receiving advance payments of the premium tax credit and whether these policies differ for those who are not. Response: We clarify in §155.430(b)(2)(ii)(A) and (B) of this final rule that the grace periods for nonpayment of premiums are not the same for individuals receiving advance payments of the premium tax credit and other enrollees. The 90-day grace period for non-payment of premiums for individuals receiving advance payments of the premium tax credit is addressed in §156.270(d). In §155.430(d)(5) of the final rule, we clarify that the last day of coverage for individuals not receiving advance payments of the premium tax credit should be consistent with existing State laws regarding grace periods for non-payment.”
Yes. That is me in the middle.
Do you like to go fishing? I do on occasion. Although, as I age I at times feel sympathy for the fish. But, I digress.
Many years ago as a student I did a family practice rotation in a great rural location in Pennsylvania. I liked this place so much I worked there immediately upon graduation from Physician Assistant school. My meager experience limited my fishing skills. On several occasions as a child and teenager I recall awakening early. I mean early in the morning and driving from our home in Southeastern Pennsylvania to the Chesapeake Bay. We rented a small skiff and fishing equipment and if fortune found us we wrangled some flounder out of that water. Most of our day, and I must admit favorite part of the trip, consisted of crashing through the waves in the skiff. Our father let my brothers and I steer the boat using the outboard motor. What a blast! Experiencing fatherhood, I realize that my father had true grit allowing us to do this. You see he didn’t like waiting and waiting for fish to bite any more than we did. But he risked his life for our joy.
One day we made a trip to a fish hatchery. The rules, you kept what you caught and paid by the pound. No catch and release. No hook or bait restrictions. No size limits. The trout hit on a hook with no bait. We bankrupted our father in less than one hour. This, by far remains my favorite fishing expedition of all time. Sadly, this hatchery was destroyed by Hurricane Agnes. I do recall several other fishing excursions. They did not involve catching fish. They involved putting a deep sea sinker and some hooks on the line and drowning worms or feeding the fish corn that fell off of my hook. They involved poison ivy , mosquito bites and on one occasion getting our station wagon stuck up to the axels in mud.
My fishing experience changed in Perry County Pennsylvania when I met Jim. Jim worked at a facility near the health center that I worked at. He loved the outdoors and loved to fish. I’m not sure what he is up to now. However, it is trout season in Pennsylvania and I’m sure he caught his limit today. I never met a man before or since who could catch trout like him. He always used live minnows and a treble hooks. He took me under his wing and taught me how to fish. He entered crowded fishing holes with the minnow and hook securely hidden in his fist and boldly asked, “How’s the fishing boys?”. Invariably the resounding response from the mob, “They ain’t biting Jim.” Jim smirked and through his bush of a beard said, “Is that so?”. He lowered his polarized sunglasses and went to work. In less than a minute at least four nice sized rainbow trout wriggled, stranded on the bank of the creek behind him. When asked what kind of bait he was using he would keep that minnow tucked in his hand, smile and say “Worms.” We went to hole after hole and repeated this action. This was a true chilly willy the penguin moment. You see, he caught my limit too.
Your probably asking yourself. “What’s this got to do with Kindergarten.” I’m getting there, I promise.
One of the things that we are taught in Kindergarten is to share. To get along with others. Hopefully with the help of our parents and what they taught us this carries into our adult lives. You see, Jim did not like to share his knowledge of how to catch fish with just anyone. I truly feel privileged he helped me. But I have to admit. I never reached the ability to catch trout like him. True, I improved. I learned catching trout did not simply involve using a minnow or how it was baited. Jim possessed a finesse, a talent, gained by experience and a love of the sport.
Do you like your job? Little wonder if you don’t, 40 percent of primary care physicians at any given time are experiencing symptoms of burnout. Do you like your patients? Do you love your job? Do you love your patients? Do you have experience and knowledge that could be beneficial to the survival of primary care? Why not share it?
I recommend a book that I read in the past and refer to frequently. Love Your Patients! by Dr. Scott Diering. This is a must read for anyone experiencing difficulty with patient satisfaction, professional satisfaction or communicating with patients.
A study conducted in 2006 published in HEALTH AFFAIRS estimated that the average medical practice spends over $68,000 communicating with insurance companies. This figure did not include the cost to communicate with Medicare. Another study published in HEALTH AFFAIRS in 2011 suggested a figure of almost $80,000. This suggests that physician practices in the United States spend 30-35 billion dollars per year communicating with insurers. This number does not include the costs of communicating with Medicare. To some this sounds outrageous. I agree it sounds outrageous. Unfortunately to physicians and their practices it is fact. It hits home to their bottom line, their time management, their practice satisfaction and the overall health of their patients. . How much cost is there in faxes, telephone calls, data and chart review to complete prior authorizations for medications, and procedure requests? How much does it cost to pay billing and coding specialists to review our charts? What about referrals for tests, specialty care, and procedures. As primary care providers we are often required to fill out prior authorizations for tests that specialists order. How did we get into this mess? In my office a part time administrative assistant specializes in prior authorizations and referrals. How about the time spent by nursing staff completing the forms and then they must be reviewed, signed and returned. Any employer knows the hourly cost of an employee is not just their hourly rate. Workers compensation, health insurance, SSI, Medicare, and other expenses add to this cost.
Following are some examples of the burden a physicians office faces. These examples occurred in my office in just the past month. We received a prior authorization request for a medication. Information was returned. The next day we received a fax that more information was required. This fax was time stamped at 7:00 am. The information was required by 9:00 am, the same day to be valid. Nobody in the office read the fax until after 9:00 am. Because of this the entire process started again with another form being completed. Does that sound outrageous? I recently completed a 4 page prior authorization for a medication my 87 year old patient had been on for 20 years without event. It was denied and I needed to schedule an office visit and change the medication. Does that sound outragous? We received prior authorization requests for generic blood pressure medication because the preferred medication was another generic. Both medications are on the Walmart 4 dollar list. Does that sound outrageous?
We have computer access interfaces that allow this to take place in real time and sometimes rapidly. However, how many times do prior authorizations for studies get refuted and go to peer review? Far too often. With the case number in my hand I call insurance companies to wrangle with their hired gun, supposedly, a practicing primary care provider. I make the call myself. I listen to the computer telling me what options to select. I even wait to listen to them all because their “menu has recently changed”. After holding the minimum required time of “eternity” I finally get to speak to someone. Now, this person is not my peer. They are not a primary care provider. They are not a nurse. They ask me the same questions that my secretary filled out on the computer interface based on my chart. Funny thing though. They give me an approval number. Spending 15 to 30 minutes on the phone I gain approval for the procedure. Playing this game for 22 years I actually spoke with a peer, a primary care provider, on two occasions.
It takes me 30 seconds to refer the patient to specialist. This specialist will order the same tests, often come to the same conclusions and treatment decisions. Unfortunately this will result in a delay to the patients treatment. This will take more time from their busy life. This will require another day off from work. From a business standpoint what decision makes sense? From our patients standpoint, what decision makes sense?
There has to be a better way of doing this.
The American Medical Association offers sample insurance contracts and advice to its members to help negotiate contracts with insurance companies. There are consulting firms who are willing to provide advice for a fee. It is against antitrust laws for physicians to group together and discuss or set prices for fee for services unless they are completly merged. Independant Practice Associations (IPA’s) and Clinical Integrated Physician Networks can negotiate with Health Mantenance Organizations and insurance companies where “financial risk” is involved. I think there must be a central location where physicians and medical offices can go to find information concerning insurance company negotiations and let their voices be heard without breaking the law.
To My Patients: Make the best of your visit.
You are important to me. I want to help you the best I can. However, I need information to do that. Some things you can do to prepare for your visit.
1. Be prepared to tell me why you are here and what you want from your visit. If you think you might forget some things, make a list. Please don’t wait until the end of the visit to tell me what you really need. If you don’t want to tell my nurse what your problem is let me know early in the visit.
2. If you were recently in the hospital, emergency room or rehab center, bring in you discharge paper work. If you recently had tests or x-rays that were ordered by another facility let me know. Bring copies of your results.
3. Show up to your appointment a few minutes early to update your information with the receptionist.
4. Bring in your medications in the original bottles. This includes any herbal supplements, vitamins or over the counter medicine. At least bring in an updated list of your medications. I don’t know what the square yellow pill is.
5. If you need refills. Bring a list of what you need refilled. If you use a mail order program, let me know the name of it.
6. Know what you’re allergic to, when you had a reaction and what happened when you took the medicine.
7. If you are diabetic. I want to see your glucose logs. If you are taking insulin I want to know how much you use and when.
8. If we asked you to get lab work, have it done about 1 week before your visit. It helps to have this at your visit.
9. If you see other providers of health care including, doctors, nurse practitioners, physician assistants, chiropractors, physical therapists or others let us know their names and office address.
10. If you can’t keep your appointment. Please let us know at least 24 hours before.
Thank you in advance for your help with this.
Your Primary Care Provider
I have a confession to make.
I prescribe drugs of abuse on a regular basis.
No, it’s not Oxycontin, Methadone, Vicodin, Percocet or even Fentanyl. It’s not Valium, Ativan, Lorazapam or Xanax. It’s not even Tramadol. I don’t have a problem prescribing these medications when clearly indicated. I don’t have a problem saying no to prescribing these medications when not indicated. I also live in a state where marijuana is illegal, so I don’t prescribe this and would not even if it were. Even when patients bully me my No means No. In fact, persuasion to receive these medications throws a red flag up that I do not put down.
What I prescribe is antibiotics. Amoxicillin, Azithromycin, Doxycycline, Cephalexin among others flow out my e-prescription bin like water going over Niagara Falls. I have practiced as a physician assistant for more than 20 years. Conference after conference, webinar after webinar, CDC report after CDC report the message is clear. Do not prescribe antibiotics inappropriately. I know the difference between viral and bacterial infections. I don’t take antibiotics when my body is being ravaged by a virus. I know that I will be sick seven to twenty one days no matter what I do. I also know that I may cough up to six weeks if I develop bronchitis. An antibiotic may give me diarrhea, yeast infections and may even cause c. difficile. Speaking of c. difficille, I have seen how sick it can make people. I have seen patients hospitalized. Lose significant amount of weight and occasionally become critically ill. The risk exists with even the most benign of antibiotics. So why do I prescribe so freely. Quite frankly, my patients expect it. We live in an “I want it now society”. Our patients are now trained as consumers. As providers we are under the gun to see more patients in less time while documenting more and meeting quality standards. I can send a prescription to the pharmacy in less than one minute. It is going to take me 2-5 minutes to educate a patient about viral and bacterial infections. I then am going to have to answer 2-3 phone calls per patient not prescribed an antibiotic over the next week. They will be requesting an antibiotic because they are no better. It is a matter of time and economics. Patient satisfaction also plays a role.
Satisfaction plays an important part in our quality grades. We are expected to meet our customer’s (patient’s) needs. Remember, “the customer is always right.” Well, we all know that our customers, our patients are not always right. How many times have you discussed the difference between a viral and bacterial infection. Your patient tells you that “antibiotics don’t help viral infections and that they just got to run their course.” You think , WOW finally someone got it. You may even give them a hand out about viral vs bacterial infections. You spend the time. You educate them. They seem happy. They understand that 2 days from now they won’t be cured. Wow, THEY UNDERSTAND. FINALLY. One or two days later they are “no better” and now want you to call a prescription in for their infection. Your task bin is full of requests for antibiotics for people diagnosed with viral infections. How many times do you acquiesce? Well, my energy level runs short, I can’t answer all those phone calls personally. The possibility of creating a patient complaint to my supervising physician, my employer, or the state medical board is not worth the risk.
I know that I am not alone. According to the American College of Physician’s there are 190 million doses of antibiotics administered daily in hospitals. Of the 133 million courses of antibiotics prescribed in the United States to outpatients every year, 50 percent of these are unnecessarily prescribed for colds, bronchitis and other viral infections.
I am trying this again. I am not going to prescribe antibiotics for viral infections or exacerbations of asthma. Just like quitting smoking, the one hundredth time might be the charm. I am handing information or emailing information from the:
CDC program (http://www.cdc.gov/getsmart/),
American College of Physicians (http://www.acponline.org/patients_families/pdfs/health/antibiotics.pdf)
I am going to try again. I hope I am successful. I am sure there will be setbacks. Hang in there. One day at a time.
To my Adult Patient:
Today I have diagnosed you with an upper respiratory infection or bronchitis. Almost all upper respiratory infections and bronchitis’ are caused by viral infections. These viral infections cause irritation to your nose, throat, vocal chords and the upper parts of your lungs. You told me about your fever, your chills, your muscle aches, your cough, your sore throat, runny nose and the mucous you are coughing up. I understand that you feel like the cat drug you in. I understand that you can’t miss work. I understand that your family depends on you. I understand that this is not a good time for you to be ill. I even understand that you may be traveling for vacation or business and that tomorrow may be a holiday.
Please read the second sentence above. Look at the word viral. This means that your infection is caused by a virus.
A virus is a very small particle that can only reproduce inside another living cell. The viruses that cause your condition actually infect the cells of your nose, throat, vocal chords and lungs and cause irritation. They make the area red, irritated, painful and produce mucous. This mucous can even be yellow or green (purulent). You can cough, wheeze, loose your voice and generally feel miserable. Unfortunately the average upper respiratory infection can lasts 7 to 21 days and the cough and irritation in your lungs can last up to six weeks.
Viruses cannot be treated by antibiotics. Antibiotics only treat bacteria.
I want you to feel better.
I wish I had a pill that could make you all better by tomorrow.
Unfortunately, these viruses must be fought by your body. Over the counter medications and some prescription medications may help with your symptoms. I cannot cure your condition. I explained this to you today. I explained that antibiotics will not help. I explained that antibiotics may cause diarrhea, yeast infections, stomach upset, allergic reactions or even serious bowel infections. I explained that you will feel better in 1-3 weeks and that you may cough for up to 6 weeks.
Please don’t insist that I give you an antibiotic.
Please don’t call me in 2 days and insist that I give you an antibiotic.
If you feel worse, or your fever rises give me a call. If you get short of breath or vomit when you cough let me know. If your throat is so sore or swollen that you are having trouble swallowing let me know. Please don’t get upset if I want to see you again. Please don’t get upset if I don’t just call in a prescription for an antibiotic. I want to do what is best for you. I want you to feel better. I care about you.
Your Primary Care Provider
Is the mental health system broken in the United States? Let me pose some questions.
1. Why do many insurance plans not cover mental health disorders.
Depression, Anxiety, Insomnia, Grief Reaction, PTSD and others can not be used as a primary diagnosis for billing purposes in these situations. What I don’t know if the Affordable Care Act (Obahma Care) addresses this. Often our patients cannot afford the costs associated with seeking specialty care and counseling. However, their copay for primary care visits is affordable. This leaves providers in a precarious position of treating patients beyond their comfort level while doing what is in the best interest of their patients.
2. Why is there a separate Mental Health System? Why isn’t it simply part of the Health Care System?
My chiropractor has developed a great wellness center. He even has a relationship with counseling services. The counselors are located right in his office. The rooms they use are tastefully decorated and lit with soft lighting. Combining the wellness of the body and the mind. Not incorporating the mental health system fully into the health care system and visa versa puts a fence that patients must cross to get the services they need. Besides razor wire lining the top of this fence, signs on it read, “STIGMA”, “SHAME”, “IT’S ALL IN YOUR HEAD”, “DID YOU CALL THE MENTAL HEALTH SERVICES NUMBER ON YOUR INSURANCE CARD”, “TRY TO GET OVER THIS WALL AT YOUR OWN RISK”, “DANGER”.
I have worked in offices in the past that had counseling services in house. I found this extremely useful. I would like to see this in my office. Better yet, an on sight counselor and psychiatrist. Awesome.
During the birth of the Mental Health System in the United States, depression, psychosis, and other disorders were poorly understood. Shame, fear, and misunderstanding led to the development of a separate system altogether. One that is at time difficult to manage and understand by those who need it the most.
I propose that that the system is not broken, it works to a degree and helps countless people every day. I do wish that the health care and mental health care systems possessed integration and cohesiveness while caring for the needs of our patients.
When doing a procedure that will expose you to blood or body fluids do you wear gloves? Of course you do. Universal precautions are standard of care and a good idea. If your patient guaranteed you that he did not have any infectious disease would you decide not to wear gloves? Of course not. That’s why we call it universal precautions.
When our patients tell us that they don’t have addiction problems or use drugs do we always trust them? With the amount of diversion of prescription medications that takes place should we trust them? I practice universal precaution when prescribing narcotics and other controlled substances on a chronic basis. I have done so for years. My patients sign a controlled substance agreement and participate in urine drug screening that can be verified by gas chromatography.
When prescribing controlled substances red flags frequently pop up: early prescriptions, lost prescriptions, a report of multiple providers or multiple pharmacies, to name a few. By practicing universal precautions we do not discriminate based on age, sex, religion, or physical appearance. It just makes sense and adds a tool to our ability to safely and responsibly prescribe controlled substances. We can not only verify that a patient is not taking unprescribed medications or street drugs but we can verify that they are compliant with the medications being prescribed. (At least to some degree)
It is important to know the limitations of urine drug screen testing. For example, clonazepam and its metabolites do not always show on urine benzodiazepines. Oxycodone is a synthetic opioid and does not always produce positive results for urine opiates. When discrepancies occur, verification with gas chromatography is vital. When initiating a program of prescription universal precautions be prepared to be surprised at what you will find. Before doing so make sure you are informed and confident in your knowledge of urine drug screening.
Below is a link to a 96 page guide produced by the US Government.
Drug Testing In Primary Care
All primary care providers face the challenge of assisting patients with chronic pain. With the upswing in prescription drug abuse, diversion and overdoses of controlled substances we also face the difficulty of deciding if we can trust what our patients are telling us. It is clear to me that pain scales don’t work in adults. When asked to rate their pain from one to ten, how many patients rate it ten out of ten. Even while sitting quietly in their chair, easily bending over to tie their shoes, and conversing in a calm manner. It makes sense to me that in an acute pain or chronic pain situation that a patient would elevate their numbers. If they say a two, are you going to take them seriously? No test exist to accurately rate pain levels, therefore the sufferers account is taken at face value.
In a perfect world there would be no need for health care providers. There would be no dishonesty and mutual trust would be a given. Unfortunately, we do not live in a perfect world. With all my heart I desire to trust what others tell me to be fact. In 47 years of life, my extension of trust resulted in bruises, heartaches and at times potential patient harm. Let me explain. Twenty years ago, as a budding enthusiastic Physician Assistant I had a pleasant, but odd, noncompliant, uncontrolled diabetic patient. Armed with the latest and greatest medical knowledge and best intentions I treated her with the standard of care. The first time I saw her I performed a monofiliament test. I asked her to close her eyes. I even blocked her view using a piece of paper. No neuropathy identified. I adjusted her diabetic and blood pressure medications and ordered labs and a follow up exam in 4 months. One month later she returned to the clinic. Her complaint, redness and swelling of her right foot, ankle and lower leg. Further exam revealed a fever and advanced cellulitis. I also found a push pin in the bottom of her foot. She faked me out. After we cleared her cellulitis and osteomyelitis I asked her why she cheated on the test. “I didn’t want you to know that my diabetes was that bad.”
So, do patients tell us untruths? Yes. Do they omit things? Yes. Pain management and controlled substance issues open universe of concerns. Some reasons untruths may be told.
1. History of undertreated pain. So called pseudo-addiction.
2. Untreated psychiatric disorders improved with the medication being prescribed.
3. Diversion- The street price for oxycodone can exceed $5.00 per milligram. At this cost, if 120 tablets of 5 mg oxycodone are prescribed a month, the potential income from that prescription is $3000 per month or $36000 per year. It is also not uncommon for people to trade prescription medications for heroin or other illicit drugs.
The question we must ask ourselves. Are we responsibly prescribing controlled substances to our patients? Are we treating pain, anxiety, or are we feeding the monkey on the patient’s back. In my next blog I will discuss universal precautions in prescribing controlled substances.