Dr. Gray's Straight Talk

Honest and blunt healthcare discussion and advice.

Posts Tagged ‘managed care’

Does Your Insurance Pay For Oil Changes?

Posted by Dr. Gray on Monday, July 20, 2009

Last time, we talked about the importance of maintenance care and the role it plays in keeping your car from breaking down. We also discussed how this same level of care and respect needs to be extended to our bodies. If you change the oil in your car, or do a tune-up to avoid potential problems… how much more important is it to do the same for your body?

In most states, we are now required to carry automobile insurance. Even with “full coverage,” we understand that this is for unexpected, unearned, and excessive costs. If you’re in an accident, insurance will cover your return to pre-accident status. Car get stolen? Insurance will help you replace it. Tree fall on your car? Auto and homeowners insurance will make good. However,… does your insurance pay for an oil change? Does your insurance cover tire replacement? What if you need a new battery? Need a front end alignment… does insurance cover that?

No? Why not?… Because that’s not what it is for! Insurance, as mentioned above, is for unexpected, unearned, and excessive costs. General maintenance is not unexpected. It is not unearned. And the cost is not excessive. General maintenance is an expected necessity due to the normal affects of normal use. One could argue that many repairs are not covered by insurance because they don’t meet these three requirements. If your alternator quits working, it may be unexpected when it happens but it has been earned by use over the many miles and hours the engine has been running; and the costs are not excessive to have it replaced. If your brake pads wear out, that is expected, earned… and again, the costs are not excessive. Transmission faulty? Both unexpected and can be cost excessive, but you’ve most likely earned (meaning caused) that trouble. Therefore, it’s not covered.

So who pays for these costs that are not covered by your auto insurance? You do, of course, and you pay it willingly because you know it keeps the car doing what you’d like it to do. Insurance will be there if you are in an accident. You will be covered if your car is stolen. Warranties (another form of optional insurance) cover you if something goes wrong within a certain time frame, but again, only if those problems are unexpected, unearned, and have excessive cost… and you pay more for the warranty. In fact, some things may be covered by your insurance, but you still may choose to pay anyway because it doesn’t exceed your deductible. And… if you submit those costs to your insurance plan, you know they’re going to raise your rates.

Health insurance and your responsibility for your own health-related decisions are no different.

If it’s so important to cover these auto expenses out of your own pocket, why is it so difficult to place that level of importance on your health care decisions? Think about it. When you need a general check up, why should you expect your insurance to pay for it? If you do expect them to pay for it, you realize that you are paying more in higher premiums than they will ever cover in general costs, right? If you need treatment for a mild sinus infection, are the costs “unearned or excessive?” If you work in the yard all weekend and throw your back out, do you refuse to visit your chiropractor if the insurance doesn’t cover it?

Furthermore, when you submit general/simple/ordinary expenses for reimbursement, your insurance company uses that information against you to raise your premiums and justify “the rising cost of health care.” While reimbursements go down, premiums go up, and coverage diminishes, you’re getting less and less for your insurance dollar… all because you didn’t want to cover a brief office exam.

What’s you best alternative? Sign up for a low-cost, high deductible catastrophic coverage insurance policy with an attached tax-free health savings account. Your costs stay low, you’re covered if anything serious happens, and you pay for your own general health care with pre-tax money. What’s even better? Your doctor’s office will love you, because they know they’re getting paid now… without all the billing expense… and without the wait. In fact, most health care facilities I know offer a 10-25% discount for paying at the time of service. Need a little more care than you can pay right now? Most offices will let you make payment arrangements, and you pay them out of the health savings account which saves you a bundle on your income tax.

Don’t kid yourself… universal or government-provided health care won’t fix this problem. The real rising cost of health care starts with our individual expectations that someone else is responsible for it.


Posted in General Health, Political | Tagged: , , , , , , , , , | 1 Comment »

Your Health Is No Longer Your Choice

Posted by Dr. Gray on Thursday, February 12, 2009

I am relatively dumbfounded right now. As part of this latest act of socialism from our federal government, they have completely done away with privacy and freedom with regards to health care. DID YOU HEAR THAT AMERICA? One of the most basic and cherished privacies we have enjoyed… the freedom to guide and direct your own healthis gone.

Yes. Slipped into the Porkulus bill, is an entirely new bureaucracy in Washington known as the National Coordinator of Health Information Technology. Sounds beneficial, huh? Yeah… let’s coordinate information. But wait. What does that really mean? Well, there are so many ramifications to this we’re going to have to look at them one by one:

  1. Mandates that all medical records will need to be kept electronically. – While this sounds good on the surface, this is just the start of the nightmare. Requiring electronic records means that several hundred thousand health care offices around the country, from medical doctors to dentists to chiropractors down to rural nurse practitioners, will be forced into a huge financial investment in new computers and software in order to comply. Think that’s all? Nope… don’t forget all educational institutions that have any health-related program. Who do you think is going to pay for this? The doctors? The hospitals? NO! WAKE UP! Those offices, hospitals, doctors, and schools will just raise their prices to cover the new expense… so you pay for it.
  2. Mandates access to those medical records by the federal government. – Yes, now that all of your health care information and secrets are in electronic form, the government wants access to review them any time they want. How would you like the government knowing all the details about your drug rehab? Or alcoholism treatments? Abortion? Sexually-transmitted disease diagnosis? Pregnancy status? Blood test results? But, why would they want this information?…
  3. Establishes a new federal bureaucracy that removes doctor or patient choice and discretion. – Although the National Coordinator of Health Information Technology sounds harmless, its true purpose is to monitor treatments to make sure your doctor is doing what the federal government deems appropriate and cost effective. Now, don’t miss it… did you really read what that sentence said? They want to “monitor” your treatments to make sure your doctor is doing what the federal government deems “appropriate and cost-effective.” In other words… it does not matter what you want, or what your doctor recommends… you are going to do it their way, or else. According to Tom Daschle, who’s book these policies are based on, doctors have to give up autonomy and “learn to operate less like solo practitioners.” What’s meant by “or else?”…
  4. Establishes penalties for non-compliance. – Doctors, health care offices, and hospitals who are not “meaningful users” will be subject to penalties, fines, injunctions, and/or charges. “Meaningful users” is not defined in the bill. That definition and the increasing stringency of enforcement will fall to the Secretary of Health & Human Services. So, if you decide that you don’t want to do what some bureaucrat in Washington says you should, good luck finding a health care practitioner that will provide an alternative because he faces fines, loss of license, or even jail. Wooo hooo… hooray for slavery! Isn’t socialism fun? Now… can you imagine a politician sticking their neck out and being the one responsible for denying and rationing health care? Of course not, so… What penalties will your doctor face, and who will make these “tough” decisions that elected politicians won’t?
  5. Establishes another expensive bureaucracy known as the Federal Coordinating Council for Comparative Effectiveness Research. – The goal of this new group is to slow the development and use of new medications and technologies because they are driving up costs. In other words… Punishment and rationing of care will be meted out by this group so the politicians won’t be associated with their decisions to place their cost savings ahead of your health.

Do you realize this Porkulus bill allocates more funding for these bureaucracies than for the Army, Navy, Air Force, and Marines… combined? There is nothing “stimulating” about these new provisions. But, why would they stick something like this in a “stimulus” bill, you ask. Well, in 1994, Tom Daschle supported President Bill Clinton’s failed massive health care overhaul. He said the main reason for failure was “debate and delay.” In other words, when people actually sat down and talked about it, they realized that not only could we not afford it, but we didn’t want it and it would not be the best option for the citizens of this country. A year ago, Daschle wrote that the next president should act quickly before critics mount an opposition. “If that means attaching a health-care plan to the federal budget, so be it,” he said. “The issue is too important to be stalled by Senate protocol.” So… the people be damned, we need to sneak this in before anyone can actually figure out what we’re doing.

Congratulations, sheeple. You’re getting the unintended consequences of what you voted for. Land of the Free… right. Home of the Brave… where? The American populace isn’t brave anymore. Neither are they free. Newsweek’s cover article this week states, We Are All Socialists Now. It’s not an discussion or article that even hints that this goes against everything The Constitution stands for… it’s an article saying that we are all socialists now… and anyone who opposes it better fall in line. I found this quote particular telling: “The sooner we understand where we truly stand, the sooner we can think more clearly about how to use government in today’s world.” You get that? The sooner you understand where you truly stand… There you go. Where do you truly stand? Newsweek has made it clear where they stand. They choose bondage. They’ve relinquished their freedom. They will capitulate to the almighty federal government at their own peril. No longer free… no longer brave…

Welcome to the United Socialist States of America.

Posted in General Health | Tagged: , , , , , , , , , | 2 Comments »

A Voice For Chiropractic Patients

Posted by Dr. Gray on Monday, January 26, 2009

The American Chiropractic Association has established a new website and organization to bring chiropractic to the people on a grass roots level. This new group is called ChiroVoice, and we all need to sign up in support of this endeavor. As our country moves in new directions, and the new administration is considering a more active role in the health care arena, we need to ensure that our representatives know what we want and need.

Through this chiropractic advocacy network, we will be working to ensure that:

  1. Congress does not restrict your access to essential chiropractic services
  2. Congress does not limit your coverage for chiropractic services within Medicare
  3. Insurance and managed care companies do not deny patients’ access to the essential chiropractic services they need

Membership is free, and will only help to protect your rights as a chiropractic patient. Please take two minutes and sign up for this worthwhile cause. Click on the logo below, and it will take you directly to the sign-up page.

Please Click Here To Support Chiropractic!

Please Click Here To Support Chiropractic!

Posted in General Chiropractic, General Health | Tagged: , , , , , , , , , , | Leave a Comment »

The Rising Cost of Health Care – Part Two

Posted by Dr. Gray on Monday, November 3, 2008

My last column gave a hypothetical and generalized view of the financial workings of a private healthcare office. In this article, I’ll discuss why I disagree with “universal health care” (UHC), and some thoughts about how insurance should be used in this country.

There are a multitude of reasons why I oppose UHC. In no particular order, I’ll try to address many of them below.

1) Government-provided or -sponsored health care further removes the patient from the health care decision process.

The rise of managed care in the 1990’s is a perfect example of this. With the introduction of HMO’s, we immediately saw patient choice limited. Patients are told who to see, what will be allowed, and how much they’re going to pay. As many of you remember, this led to long lines, substandard care, impersonal relations with your doctors, inconvenient office locations, no patient control, and no doctor control. In short, a bureaucrat is placed in the position of making your health care choices for you; and he’s making choices based on the bottom line instead of your health. With all that, costs have continued to rise, and general health statistics have continued to decline.

2) UHC is not free!

This is one that upsets me. I often hear people talk about how “the government should provide free health care.” Let’s get one thing straight… the government has no money! As such, they can not provide you with anything. Every time you ask for anything from the government, what you are really doing is asking your neighbor to pay for it. Through increasing taxation, you are forcing your neighbor to pay for it. There are certain things a society is responsible for as a whole, but why should your neighbor be responsible for your health care? Put it another way… if you choose to take care of yourself, eat right, and exercise, why should you have to pay for your neighbor’s ailments related to smoking and obesity?

3) UHC will diminish patient choice and lead to rationing of care.

Think this won’t happen? Ask them in Canada or Great Britain. In fact, we need only look to… Oregon! In July of this year, a woman on the government-sponsored Oregon Health Plan was denied cancer treatment, and instead offered… death. As reported in the newspaper The Oregonian, “After her oncologist prescribed a cancer drug that would cost $4,000 a month, Wagner was notified that the Oregon Health Plan wouldn’t cover the treatment, but that it would cover palliative, or comfort, care, including, if she chose, doctor-assisted suicide.” This is only one example, but I’ve got volumes of research detailing this reality.

4) UHC will not lead to an increased mentality of prevention.

I keep hearing that increased access to care will cause more people to practice prevention. This is absolute hogwash. Right now… practicing a preventive lifestyle is free. A preventive lifestyle does not merely consist of mammograms and prostate checks. It is primarily making the right choices on a daily basis. Prevention is largely related to your dietary choices and activity level… not how many times you see the doctor. In fact, I would argue that UHC would actually decrease thoughts of prevention. Why worry about prevention when you can just run down and get treated for free, right?

5) UHC will stifle innovation and advancements in health care.

Nearly all advancements in pharmaceuticals and medical technology in the past 50 years have come from the United States. Why? Because there is financial incentive to do so. If the potential for profit is there, companies will invest and research for ways to fill that void. UHC, however, resists new treatment methods, techniques, and medications. A good example is the French physician who patented a new medication for dialysis patients that has become the standard of care in America because of its superiority. Practicing in London, he’s not able to use his own patented medication because the NIH refuses to pay for it; choosing instead the cheaper, yet less effective, old medication.

6) The federal government has no Constitutional authority or obligation to provide health care.

The fedgov’s primary role is supposed to be to protect our rights to life, liberty, and the pursuit of happiness. Notice, that role is to protect, not to provide. As per the tenth ammendment to the Constitution, anything not specifically delegated to the federal government in that document is reserved to the states or to the people. Every dollar that goes from the fedgov to this new entitlement program will take away from the fedgov’s ability to protect those rights. Freedom comes from our rights, not our government. If your freedom, or your healthcare, comes from your government, you are no longer free because they can also take it away.

Whatever happened to personal responsibility in this country? Why has the cost of health care risen in this country? Because the people have increasingly removed themselves from the responsibility of their health care decisions. Employer-provided insurance insulates the patient from the cost of insurance, and removes the patient’s right to use the market to their advantage. How many consider that a $20.00 per hour job with benefits is actually a $30.00 per hour job but one third of it goes to insurance premiums? If you were acting like it was your money… and it is your money… you would seek to find better coverage for less money, and take the balance home for your family. However, most fall into the trap of only making $20 per hour and taking whatever plan the company chooses. Do you think the company is going to choose the plan that’s best for you? Or do you think they are going to choose the plan that costs them the least?

Is insurance necessary? … Yes. But we are going about it the wrong way. It’s time to return the responsibility for health care decisions and finances to the individual. We should reject employer-provided insurance and take the increased pay instead. We should remove stifling laws that prevent competition between insurance companies and across state lines. Unfortunately, the insurance industry has not proven capable of regulating itself. As a cost for the decreased restrictions upon their industry, they should be required to practice full, complete, and open disclosure. Already charged with and funded, the FDA and the Department of Justice can start doing their jobs… and protect the American people, as opposed to selling out to the highest corporation. Why would they do that? Because people will be paying attention again.

Our mentality about insurance must change. Coverage should be low-cost, high deductible, and rarely used. Most regular doctor visits should be paid for out-of-pocket, saving insurance coverage for catastrophic events or illness only. When’s the last time you used your car insurance to pay for an oil change? What’s that… they didn’t pay for it? Then why did you have it done? What’s that… good maintenance? Why should your body be any different?

If your neighbor doesn’t take care of his car, neglects to perform maintenance, and hot rods it around town… should you be forced to fix it for him when it breaks down? No? But, he needs that car to get to work. He needs it to take care of his family. You seeing the parallel here? Responsibility lies with the consequences of one’s actions and choices. This applies across the board. Does this mean I disagree with any form of government health care assistance, such as Medicare, Medicaid, etc.? No. But it should be the exception, not the rule. Some people need help, that’s a fact. And the American people have proven themselves exceedingly generous when left to charitable giving. Having to resort to public support should be discouraged instead of encouraged. It should be used as temporary assistance to help someone out of their current situation, not as a permanent way of life, except in those cases involving permanent disability. Even then, private charities have proven more generous and more efficient than anything the federal government could ever sustain.

In conclusion, take control of your own health care. Value it and value your body. Take responsibility for the consequences of your actions and choices. Once you realize that you are the only one in control, making good choices becomes easy. Vote for more freedom, not more governmental control. Pay for your own insurance, and maintenance care. You’ll value it more, get more out of it, and you’ll live a longer, happier, healthier life.

Posted in General Chiropractic, General Health | Tagged: , , , , | 1 Comment »

The Rising Cost of Health Care – Part One

Posted by Dr. Gray on Tuesday, October 28, 2008

The “rising cost of health care.” How many times have you heard that rhetorical statement made to make a political point? Being that relatively few of you are in the health care field, I thought I might shed a little light on the inner financial workings of a private health care office. Not too detailed, just a simple exploration.

I have a small health care practice in a suburb of Kansas City. While, technically, a “small business,” we are comparably considered one of the busier offices in the area. When I take into account all of my overhead just to open the doors of my office, and factor in the cost per patient associated with that cost, it costs me $27.00 every time a patient walks through the front door. If that patient converses with the front desk, then turns and leaves, I just lost 27 bucks.

Now, for reimbursement… if my normal office charge is $50.00, that’s a profit of $23.00, of which I’ll pay roughly 38% in taxes. So, I’ve just made roughly $14.00 for risking my career, reputation, livelihood, and ability to support my family in that one visit. Now… multiply that by the number of patients seen per day, week, month, etc. and you can begin to see the amount of risk (not to mention time, money, and effort that must be expended in order to achieve the education level of doctorate) that must be taken in order to make a significant living as a doctor.

However, that’s only if we’re talking on a cash basis and 100% collections. The fact is that nearly 83% of my patients have some form of insurance coverage for my services. For most doctors, that percentage is higher. The two most common scenarios encountered in our office involve “in-network coverage” and what is known as a “global fee cap.”

Although a living can be made operating “out of network,” it is more difficult, marketing intensive, and involves more direct cost to the patient. Also, the mentality of patients is that if they are paying for insurance, they’re damned sure going to go in-network to take advantage of it. That can be argued as a positive for the doctor in that they have easier access to the patient. Therefore, we remain “in-network” providers for the majority of insurance plans offered in our area (therefore, cash basis does not apply).

In order to be “in-network” we are forced to sign a contract agreeing to a discounting of fees, “peer review,” and relatively little legal recourse regarding foul play by the insurance company due to forced arbitration agreements. This discounting of fees averages to approximately a 32% fee cut, and can be arbitrarily changed by the insurance company at will (again, little recourse due to forced arbitration and unlimited legal and financial resources of the insurance companies). “Peer review” refers to an employee doctor that is hired by the insurance company to deem care as medically unnecessary, thus not reimbursable and not collectible. This accounts for another approximate 10% cut to the collectible portion of services rendered. Another 10% cut can be attributed to unpaid deductibles, copays, or cash portions.

Therefore, the majority of collectible services in the average health care office is only 48% of the actual fee for service rendered (after speaking with several other doctors, this percentage is sometimes much lower). In our original estimate of a $50.00 office charge with $27.00 in overhead, I would lose $3.00 every time I treated a patient. So, in order to make that same paltry $14.00 profit margin, my fee for a simple office call must be $103.29. You following me here? {14 = 0.62(y*.48 – 27)}

“Global Fee Caps,” on the other hand, are a whole new animal. In the past couple years, United Health Care, Coventry, and others have seen fit to institute (remember the arbitrary nature discussed above with which they can change reimbursements) this monstrosity on the health care world. A “global fee cap” is the determination that every visit, regardless of what services are rendered is capped at an arbitrary, pre-set amount. The rate is currently set at $42.00. So, no matter what situation the patient presents with, and no matter what services are necessary, the reimbursement is capped at no more than $42.00. Need a quick consultation? $42.00. Need a complete examination, with x-rays, and therapy for the reduction of pain? … 42 bucks. That’s it.

“But you would lose money on every patient, why remain in-network?” you say. Here’s the rub. These patients have been hit with a $35.00-40.00 copay per visit, therefore, there is an immediate profit of $8.00 – 13.00. So… the patient pays, let’s say, a $35.00 copay at the time of service… we provide the least amount of care possible, yet still responsible, because any service beyond $42.00 is non-reimbursible (and not billable to the patient)… and the insurance company decides to react in one of two ways: they pay the $7.00 balance, or they initiate the “peer review” process to determine if they can get out of paying it by declaring it medically unnecessary. Want another rub? If they declare it “medically unnecessary,” they not only don’t pay the balance, but they demand you reimburse the copay to the patient… even if the patient disagrees with the determination.

The decision to remain in these networks is multi-faceted, even though the compensation is small. First, is the sincere desire to help as many patients as possible. Second, is in the opportunity to stimulate referrals of other patients who not only need care, but may have a different insurance plan. Third, is the fact that the patient may have never chosen to come to my office in the first place if I wasn’t “on their plan.”

What’s worse? Some of these plans have now increased the copay amount above the level of the “global fee cap.” In essence, the patient has been sold phantom coverage in which the insurance company is not really providing anything, but is collecting premiums.

Why are health care costs “rising” in this country?

Pure and simple… the insurance industry, and the public’s mentality about what and how insurance should be used.

More about this topic in part two… when we’ll begin to discuss how “universal health care” will fit into this mess. In the meantime, please feel free to comment.

Posted in General Chiropractic, General Health | Tagged: , , , , | Leave a Comment »

Study Reveals Chiropractic Care Actually IS More Cost Effective

Posted by Dr. Gray on Tuesday, July 29, 2008

From: Arch Intern Med 2004 (Oct 11); 164 (18): 1985–1892 Antonio P. Legorreta; R. Douglas Metz; Craig F. Nelson; Saurabh Ray; Helen Oster Chernicoff; Nicholas A. DiNubile

Department of Health Services, UCLA School of Public Health, Los Angeles, Calif

BACKGROUND: Back pain accounts for more than $100 billion in annual US health care costs and is the second leading cause of physician visits and hospitalizations. This study ascertains the effect of systematic access to chiropractic care on the overall and neuromusculoskeletal-specific consumption of health care resources within a large managed-care system.

METHODS: A 4-year retrospective claims data analysis comparing more than 700,000 health plan members with an additional chiropractic coverage benefit and 1 million members of the same health plan without the chiropractic benefit.

RESULTS: Members with chiropractic insurance coverage, compared with those without coverage, had lower annual total health care expenditures ($1463 vs $1671 per member per year, P<.001). Having chiropractic coverage was associated with a 1.6% decrease (P = .001) in total annual health care costs at the health plan level. Back pain patients with chiropractic coverage, compared with those without coverage, had lower utilization (per 1000 episodes) of plain radiographs (17.5 vs 22.7, P<.001), low back surgery (3.3 vs 4.8, P<.001), hospitalizations (9.3 vs 15.6, P<.001), and magnetic resonance imaging (43.2 vs 68.9, P<.001). Patients with chiropractic coverage, compared with those without coverage, also had lower average back pain episode-related costs ($289 vs $399, P<.001).

CONCLUSIONS: Access to managed chiropractic care may reduce overall health care expenditures through several effects, including (1) positive risk selection; (2) substitution of chiropractic for traditional medical care, particularly for spine conditions; (3) more conservative, less invasive treatment profiles; and (4) lower health service costs associated with managed chiropractic care. Systematic access to managed chiropractic care not only may prove to be clinically beneficial but also may reduce overall health care costs.

Posted in General Back Pain, General Chiropractic, General Health, Low Back Pain, Neck Pain, Other Pain Conditions | Tagged: , , , , , , | Leave a Comment »

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