Polly - Here Are My Thoughts On The Future Of Mail-In Tests

[tex]

Hi Polly,

Your thoughts on mail-in tests are interesting. How will folks know which ones to take advantage of? I can envision a slew of unnecessary tests being offered for way too much $$$. But it sure will be convenient.

IMO, most people will do their homework, possibly by exchanging information on internet forums, the way that we do here, or maybe by subscribing to newsletters by third-party organizations, (possibly linked with professional medical advisers), or maybe even by discussions at local organizations, where information is shared, again, possibly including seminars by recognized medical professionals, (as opposed to the "highly-questionable" medial "experts" so often seen on the infomercials so common on late-night tv these days , selling colon-cleansing treatments and various other snake-oil medicine). Local and internet support groups may arise to deal with general health, instead of just offering support after the fact).

The thing is, IMO, people are paying way too much money for unnecessary tests, right now, and have been, for many years. In many situations, doctors order a lot of overpriced, unnecessary tests, just to "cover their butts", (or so we commonly suspect, at least). Many of those tests could be avoided, if the doctors involved would just do a little more thinking, and relying on their experience, their medical training, and good old common sense. Today, it seems as if doctors don't want to waste any time thinking. They prefer to order more tests, so that all they have to do is interpret the results, and act according to the test results. It's quick, (for them, not the patient), and less stressful, (again, for them, not the patient), because they can reserve more of their "thinking time" for fun things, such as how to improve their golf score, or where they should go on their next vacation. I'm certainly not trying to suggest that all tests are bad, because many/most of them are vital, and they save many lives every day - I'm just saying that they are just diagnostic tools, and should be used appropriately, as needed.

The point is, why should a doctor spend all that money, and do all that hard work, to graduate from medical school, if he or she is going to let lab tests do all of his or her thinking? If tests are the main ingredient to health care, then a doctor isn't even a necessary part of the equation, until later in the process, because it doesn't take a rocket scientist to figure out which tests would be appropriate, in most cases, (provided the patient does his or her homework).

Here's the real "kicker", though. IMO, once labs start pitching the use of their tests directly to the consumer, not only will competition increase, but prices will come down. Right now, labs have no real incentive to be competitive on pricing their tests, because doctors, clinics, hospitals, etc., not only pass on the full cost of the tests, but presumably add their own "markup", to boot. It's no hide off their butts, if the tests are overpriced, because the insurance companies, and/or the patients themselves, are stuck with the bill. The more expensive the test, the larger the "markup", that the clinics, hospitals, doctors, etc., can justify, so as a result, it would be counterproductive for them to sincerely campaign for lower test prices.

Not only that, but the overly-complex bookkeeping, caused by all the pricing games played by the insurance companies and the medical entities, undoubtedly results in an astronomical amount of waste, in the long run. IMO, there is probably no such thing as a hospital bill that would stand up to close scrutiny during a strict audit. Why? Because they are too complicated, (IOW, too long and loaded with unintelligible code and abbreviations), for the average consumer to understand. So who knows what they are actually paying for many of those tests? If a consumer orders a test direct from the lab, though, there is no question about what it actually costs, and anyone can understand it. It's almost as if the medical establishment were intentionally trying to keep patients in the dark, about what various components of their bills actually cost. I'm pretty sure it's not intentional, but the complexity of it all, certainly seems to lead to that result. I think that many patients are becoming increasingly dissatisfied with living "in the dark", and they're yearning to step out into the light. They want some control. Obviously, that's not true of every patient - some just want to go to their doctor, get a few pills, and not have to worry about the details.

Hmmmmmmm. I apologize. As usual, I seem to have gone off on quite a few unnecessary tangents here, but anyway, my point is that I think that medicine is slowly evolving away from the mysteries that surrounded it in the dark ages, and most of the change is good, but some of it is not so good, not the least of which is the cost, and subsequent unavailability of good, affordable care for a high percentage of the world's population. In many places, it takes way to long to get an appointment, especially to see a specialist, and for all of us, the cost of treatment for a major illness can easily amount to a King's ransom.

While I'm on the subject, the insurance companies are just parasites that have evolved to add a "middleman's" surcharge to the process, because as we all know, there is no Santa Claus - we are Santa Claus, and we not only have to pay for every penny that the insurance companies pay out, but we also have to pay the fat salaries of their overpaid executives, and their underpaid staff , (to say nothing of having to pay for their plush offices). Without the insurance companies, health care would be a lot cheaper, (and the bookkeeping might be simple enough that any of us could understand our bills).

OK, sorry, I got off on a tangent again, but my point is that if we are willing to take on some responsibility for our own health, we can cut our health care costs considerably, in the long run, and one way of doing that would be to utilize mail-order tests, that would cut out all the middlemen. Obviously, of course, this is only going to apply to certain types of tests, that are suitable for this sort of approach. I'd better wrap this up, before I get carried away , again.

Love,
Tex

[Polly]

Hi Tex,

Most interesting! As usual, you have done lots of good thinking and analysis in presenting your opinion.

I think there is another hugely important factor that drives the way medicine is practiced....the lawyers. Most docs have to practice defensive medicine because if they haven't done every possible test available, they will lose their malpractice cases and possibly their licenses. Did you know that 7 out of 10 OBs are sued?......people seem to forget that having a baby involves risk (just like any other experience in life).

When I was in training, we were taught to use lab tests sparingly, and in a sequential order as we went about a differential diagnosis. In fact, when I took National Medical Boards, Part III, at the end of my intern year, you achieved the highest grades for using the least number of lab tests to come up with the diagnosis in the test cases presented. Most docs love the intellectual challenge of figuring out a diagnosis in a step-wise process using the least tools possible; however, once the lawyers got into the act, this changed. Another reason it is no longer possible to do tests step-wise for hospitalized patients is because the insurance companies dictate how long a patient can be in the hospital. You must do all of the tests at once before the patient gets kicked out in 24 or 48 hours.

I truly believe that most of my colleagues would prefer to use a minimum of lab tests, but the system will no longer allow it. Sigh.

Love,

Polly

[tex]

Hi Polly,

I apologize for not specifically pointing out that oppressive justice system practices are indeed the primary reason, (perhaps the sole reason), why doctors tend to use the "cover their butts" option when selecting tests. There's no question that an out-of-control legal justice system, that has convinced consumers that "whenever anything goes wrong, it's time to call in the trial lawyers", is the source of virtually all of that foolishness. To be honest, I'm rather surprised that as many as 3 out of 10 OBs are able to "escape" without any liability suits.

That's also the reason why I gave up selling my products through national chain stores. Even though my products were/are nothing but cleaned, bagged, whole kernel corn, with no additives, preservatives, nor anything else, the national retail store chains expected me to carry a multi-million dollar liability insurance policy, with them specifically named as the beneficiary, just in case, "someone tried to swallow a handful of it, and choked to death". This wasn't even food corn, it was animal feed, and was clearly labeled as such.

As far as insurance companies dictating how long patients can remain in the hospital, and how their care should be micromanaged, I stand by my opinion of insurance companies, as stated in my previous post. I'm sure that a heck of a lot of doctors would, as you say, love to go about their business as they best see fit, if the system would just let them. I find it difficult to foresee that ever happening, though, as more and more industries are dominated by fewer and fewer giant organizations, including governments, with their tendency to move toward national health care systems.

Are you aware of the tort reforms made by the Texas legislature over 5 years ago? The reforms reined in the out-of-control tort claim lawyers, and brought some common sense into the process, by placing reasonable caps on malpractice awards in Texas. As a result, we no longer see cases where a patient views a medical malpractice suit as a surefire way to "win the lottery", and their lawyers no longer see the medical industry as their own private gold mine.

Now, we have good doctors moving into the state, to relieve the shortage, and it's not as difficult to get good care, (we don't have to wait 10 years to get an appointment). In fact, the number of doctors applying to practice in Texas has increased more than 50% every year, since then. Insurance companies are returning to profitability, and malpractice insurance is much easier to obtain. Unfortunately, though, so far at least, this savings has not been passed on to consumers. So who's dragging their feet? Where is all this money that has been saved, going? I'm guessing, that it's been ending up in the pockets of insurance companies, hospitals, and doctors, since they're the only ones likely to be able to get their hands on it. And, as usual, the patient is stuck with the bill, with no recourse but to pay it. <sigh>

As they say, "everything changes, but everything stays the same", at least as far as the cost to the consumer is concerned. That's why I believe that patients are ready for a little more freedom, in their medical choices. Maybe if more states pursued this issue, and put some reasonable caps in place, we would all see some benefits, but I'm not holding my breath. Please read this, if you're not familiar with these tort reforms:

http://www.dallasnews.com/sharedcontent ... 983f4.html

Please note that the article at the above link was written about a year and a half ago, but I doubt that the trends described there have changed much since then.

Love,
Tex

[Gloria]

I'm going to add my two cents here. Is there room on the soap box for one more person?

I agree that many unnecessary tests are ordered due to fear of lawsuits and the patient bears the brunt of the cost. But I disagree that insurance companies are responsible for the increase in the costs. In fact, I think the opposite is true. I'm always amazed at how small the insurance-negotiated price is for an x-ray, for example. If you scrutinize your hospital bill, you'll find that the hospital bill has been reduced by 2/3 or more due to contracts with the insurance company. Rather than raising medical costs, I think that the insurance companies are keeping them down - as long as you are part of a group plan with a national company that negotiates contracts. In fact, that's why I have to find a new Internist. He refuses to enter into a contract with my husband's health insurance company and we'd have to pay the full $120 cost for an office visit. And we aren't even eligible for Medicare yet. I understand that many doctors won't accept Medicare patients because of the low reimbursement.

Continuing that vein of thought....
I suspect that one of the reasons that Dr. Fine is not in any hurry to publish is because his tests would more likely be covered by insurance plans. But it's almost certain that insurance companies would negotiate a payment far lower than the amount he presently charges independent customers. His lab is probably making a pretty good return on the lab tests right now. But once it accepts insurance payments, the lab would have to analyze many more specimens for the same amount of return. Its work load would increase, but it's quite probable that its income would not increase proportionately.

I do think that independent testing is a great idea - if the costs would compete in the free market system. If the system is allowed to flourish, then competition might keep the costs down.

Gloria

[tex]

Is there room on the soap box for one more person?

Always!

If you scrutinize your hospital bill, you'll find that the hospital bill has been reduced by 2/3 or more due to contracts with the insurance company.

I'll grant you that it appears that way on the surface, and that's exactly what the insurance companies want their clients to believe, but in reality, that's just part of the game that insurance companies and hospitals, (et al), play. Insurance companies try to pinch every penny that they can, (to add to their bottom lines), and this also serves to convince their clients that they're getting them a good deal, and hospitals, et al, just jack up their prices accordingly, so that the discounted price they receive, will match what they actually need to receive for the service. If the insurance companies didn't play that game, the hospital bills would presumably reflect the correct price in the first place.

A side effect of all this "financial finessing", done by the insurance companies, is that in some cases, where the insurance companies and/or the government's medicare program refuse to allow what the hospitals actually need, (or feel that they need), as compensation for any given service, do you think that they, (the hospitals, et al), just eat that loss? Would you? Nope, they simply charge cash customers, (who don't have insurance), more, to make up for their losses, (or perceived losses). So, in effect, cash customers, (who usually can least afford it), have to subsidize the insurance companies, so that the insurance companies can afford to hire more accountants, to figure out new ways to "milk the system".

Trust me, as a student of engineering, mathematics, and physics, I can guarantee you that there are no free rides in the real world. The insurance companies suck a tremendous amount of money out of the health care system every year. How do you think that they can afford to pay billions of dollars to all those employees? The money has to come from somewhere - it doesn't just come floating down from heaven. It comes from the pockets of those who use the health care system. Where else could it come from?

As for Dr. Fines part, you might be right, but, of course, he wouldn't have to accept insurance payments that weren't adequate, if he chose to do so. Most likely, he would simply play the game that everyone else finds necessary to play, and he would just jack up his prices. Once again, the cash customer would be the loser, as soon as the insurance companies moved in.

IMO, the biggest disincentive of accepting insurance, is all the paperwork involved. If it weren't for all the insurance company bickering, and all the superfluous paperwork that they require, before they will pay what they owe, a medical office could probably get by with half to a third of it's normal accounting staff. That amounts to a lot of drain on the medical system, also. I'll bet that Polly can relate to that.

Please don't misunderstand me - the insurance companies do provide a benefit for many people. But they rob from everyone else, to do that, and they take enough out of the system to pay all their employees, and make a nice profit, to boot. I find it difficult to categorize them as the "white knights" that some people perceive them as. Equal opportunity Robin Hoods would probably be a more accurate comparison than white knights, since they rob from the rich and the poor, alike.

I realize that the way we are likely to view insurance companies is bound to be heavily influenced by our personal experiences with them, and if you've received more benefits than you've paid out, over the years, you probably have a good opinion of them. If, however, like many/most of us, you've paid them countless thousands of dollars over the years, and then had to haggle with them over virtually every little claim that you've filed, and even been totally denied, a time or two, you probably won't have near as high an opinion of them. Put me in the latter category.

Tex

[Polly]

Hi Gloria!

Always good to hear from you.

Hi Tex, Thanks for the TX tort reform info. I am going to check it out. We desperately need that kind of reform here. Many docs have left/are leaving practice - they must be coming to TX!

Paperwork...........you are correct! The system is broken. Each insurance co. has its own forms and requirements. For example, one company might require a specific strep lab test to be done before it will reimburse for diagnosis and treatment of the sore throat. Another co. might require a different (or no) test. If the doc doesn't pay attention to this, the patient can be charged out-of-pocket for certain services.
And then, it is likely that the family will be with a different insurance co. the next year, with all different requirements. It is a nightmare!

Gotta run - on the move today. It's always a pleasure having our soapbox discussions.

Love,

Polly

[Lucy]

Hi all,

I've skipped over the last few entries in the interest of time, but as one with plenty of experience in trying to get insurance reimbursements to even cover the providers' costs, let me tell you that the money is NOT going into the ordinary private private practice physicians' pockets -- maybe a few administrators and salaried government paid types, but not Joe, the doctor on the corner's. They have absolutely no control over what they get paid unless they work more hours, IF they have any left, but then some people can get by on three hours sleep, I suppose! Unfortunately, there are enough salaried administrative and teaching docs who get paid much more to bring the average way up when it's reported what they presumably make in the press. I really have a hard time believing their stats anyway. Then, you have the fradulent types who seem to get by with things no matter what profession they are in. Government always lead to massive corruption, and the government is the hand in the glove behind all the reimbursement systems in existence today.

Thanks for explaining how caps on PAIN and SUFFERING damages have helped the situation tremendously in Texas! This does not prevent someone from obtaining actual cost recovery for their treatment, for an FYI, by the way, and this is only right.

Let me say that there are a multitude of reasons why costs have gone up. Probably the greatest reason is that we simply have so much more diagnostic technology and things we can do for people with all the scientific advancements that have been made during my lifetime. When I was a child, the only antibiotic that was available when I was so ill in the hospital was penicillin which saved my life. Fortunately, I've never had to use a neuroleptic, but I do know that back before 1950, even Thorazine wasn't available.

As an analogy, suppose you went to a store back during the depression (assuming you had money back then), and put one of each "necessity" into your imaginary shopping cart. It wouldn't amount to a whole lot, now would it? Fast forward to today, and how many items would be considered a necessity compared to back then, and how much fuller would your shopping cart be at checkout? None of us really wants someone to suffer needlessly when there is something available to help them, particularly those who've deliberately studied and worked hard just to help their fellow man. This is the "compassion crunch" that we are currently in. Think of it -- there's really no other area of life in which everyone is considered (by most people, anyway) as deserving of the "Cadallac" version of a particular necessity of life. In medicine, however, we want everyone to have the best care possible.

Then, in more populated areas, the real estate for a doc's office goes up and up, despite reimbursements coming down all the time. Every provider of medical equipment charges whatever they can get -- no price controls on them. Same goes for one's accountant, attorney, and other rendered services that aren't controlled by price controls. Somewhere something's got to give!

Since '93, when my mother was finally able to be diagnosed as having Parkinson's, I'm almost out of fingers counting all the primary care docs she lost to retirement YOUNG, due to this mess that the government really got us into when they set up the system of diagnostic codes and treatment codes working through insurance companies in setting up Medicare, etc. That enabled all insurances to use the same system...AND, the doctor's time in looking up all these thousands of codes due to the insurance companies not hiring anyone who has the faintest idea what a medical term means, and therefore, not being able to look up the appropriate codes themselves! So, what you've got is a person who has a high school degree...maybe...telling a doc what he should or shouldn't prescribe in a given situation.

There's no stipulation about profiling in this game. If your numbers, in terms of diagnoses come back too high on something (like above their averages among all physicians), the government's computer's will spit out this information, and you'll get a nasty letter from them with some sort of punishment. What then will happen is that if you diagnosis someone with a very rare disorder, then your number of diagnoses for this condition will be too high...EVEN IF THAT'S THE ONLY ONE YOU'VE E V E R DIAGNOSED in your career, it's still considered, BY THEM, to be too many! How would you like to have a system like that grading your papers everyday?! I should think they would be glad that you'd been smart enough and thorough enough to figure out what was causing the patient distress, but nooooo...not MC, which is really run and set up by insurance companies.

And, I forgot whether I mentioned this or not, but docs are, by law, not allowed to mark up lab work and the diagnostic tests that they order. I think that Polly said it well...how that most of docs were trained to just do necessary diagnostic work ups in a sequential order that made sense. Every situation is different, so I dread being one of the poor patients who doesn't fit into these insurance companies stereotypical care patterns. Actually, I've run into this already in both my own hospitalizations and my mother's. It's totally ridiculous how decisions are made by people not even remotely involved in a patient's care. Some are social workers, and others don't even have that much training, but they just exist to keep the insurance companies from making the hospitals go bankrupt, and in truth, THEY decide when a patient gets kicked out of the hospital.

There's probably alot more that I could say, but in my experience, particularly in the early days of all this, people wouldn't believe you when you'd try to explain it to them. It was alot less complicated in the early stages. I, personally think that docs should've just refused to accept ANY insurance...that was their fatal flaw, I'm afraid. They would've had to do it individually, however, as the law prevents physicians from anything remotely like collective bargaining, so they can't even discuss their pricing with another physician without fear of being thrown in jail.

Also, MC sends things that are, in my opinion, deliberately confusing to their recipients just to make the provider look like the bad guy, and of course, they are "here to help you," as the old goes. This is government thuggery in the classic sense. It really disturbs me that such, frankly evil people rise to the level they do in this country -- CEO's, high profile politicians, elite athletes, educators, you name it. Believe me, they make sure that all the people coming along under their charge are equally evil by running off all the honest, decent people below them. After all, who wants someone honest watching everything they do while they're in power, who aren't sell outs, and what decent person wants to work in a corrupt system if they are honest and just trying to do a job well -- that makes the jerks look bad by comparison, and will get you in more trouble than doing something illegal! As you can probably tell, I've had lots of government work experience in the past. All you have to do is be in the wrong part of the system long enough to put the pieces together. Thankfully, I got out while I was still physically able.

Yours, Luce

[MaggieRedwings]

Hi All,

Great reading this post. Will be short and sweet on this one. Hate insurance companies, lawyers and with the exception of Polly, my heart and retired GP - I have lost all faith in the medical community too. Mostly it came from the vertigo/ear rock/whatever problem (that I still have) and the way I was treated (mistreated) and the amount of money for tests that no one could decide on after having them done. I love the idea of caps and feel bad that docs have to pay a ridiculous insurance rate and are leaving the profession.

Why can't we just have a more simple life as the Cleaver's had?

Love, Maggie