Health care is an unusual industry.  And by health care, I mean the whole system (so sick care, too, even though many people call it health care).  In any other industry, a service is rendered, and the customer pays for it.  Last time I went to a restaurant, I ordered what I wanted, it was delivered with a smile, and I paid the bill PLUS a tip.  There were no negotiations, no, “let me take a printout home and show my wife and see if she’s ok with it.”  No, “You know what?  I usually pay for this from a different kind of account.  Will you send me a bill so I can pay out of that account, and then I’ll have a receipt with diagnosis codes so my employer can reimburse me for my deductible?  I’d really appreciate that.”  No way!  the bill came, I put cold, hard cash on the table, and I left.

People might respond, “Yeah, eating at a restaurant is optional, but my health care is not.  I need to take care of my health.”

While you’re close, you haven’t quite got it.  First of all, eating is not optional.  Eating in a restaurant is, sure, but I still had to eat, and I still had to pay for my food, even if it were preparerd at home.  Further, if you’re interested in taking care of your health, then take care of your health.  Don’t wait until you get sick, and then pay someone to help dig you out.

As a comparison, if we’re talking about wealth (instead of your health), it wouldn’t make any sense to lose all your money, and then pay someone to help you get more money, would it?  Of course not.  In the same sense, it wouldn’t be prudent to pay people to look at your financials while their only goal was to tell you early in the game how you’re going to lose all your money.

If that doesn’t make sense, then why would it be any different when people do abosolutely nothing to enhance or improve their health and then pay gobs of money to people to say, “Yep, you have _______osis and you’re going to die.”  Or, “It looks like you may be developing something in that breast.  We should fill you with drugs and then cut things out as a preventative measure.”

Preventative? Since when was early detection (finding something that’s already there) considered prevention (not allowing something to develop or happen)?

So, clearly, the system is flawed.  Doctors study hard for a long time, go into tremendous amounts of debt, serve communities whole heartedly, and then get asked to wait on getting paid by patients, get forced to negotiate their rates with insurance companies, and have to pay staff members just to make sure they’re getting paid.  It doesn’t make sense.

People come into clinics and say, “I want your help, but only if someone else pays for it.”  So the whole system is upside down.  We get that.  But what does that do to ethics?  Does it allow us to compromise our ethics, just because the system is flawed?

I recently went and saw an MD through the University of Michigan.  I don’t do this very often (see above), but I had some questions, and she’s a friend of mine, and I take care of her in my office.  We got into a decent conversation because I was concerned about some things, shook hands, and I left.  On my way out, I paid my copay for an office visit (without any fussing) and got back to my office.  A few weeks later, a bill came from UM Health Systems, and I noticed my insurance had been charged for the highest level office visit allowed (CPT code 99214).

This didn’t sit well with me at all, because I know how billing and coding works, and, frankly, based on evaluation and management guidelines, that visit would not qualify for the code for which she charged my insurance. In their defense, however, they did draw blood, so maybe it does.   Then I asked myself, did this happen because we get kicked around by insurance all the time, and this is one way to get paid a decent amount for an office visit? The charge was $144.00 (which I am not gawking at, it’s the code I have trouble with).  I paid a $10 copay, insurance covered $68.42, the practice wrote off $45.58, and I’m left with a balance of $20.00 (because of my 20% coinsurance).

So let’s look at this a little more closely:

Initial Charge: $144.00
Estimated cost to charge me (clerical staff, envelopes, printing, postage, return envelope): $4.61
Cost to re-bill me if I don’t pay my remaining $20.00 in a timely manner: $0.61 each

Now, what if I had offered to pay cash instead of them doing the insurance billing?  I had to pay $30.00 anyway.  What if I offered to pay the full $98.42 they received for the visit?  Maybe they would have offered a 15% prepay discount so they get their money up front instead of waiting weeks to months for it.  Would they still have up-coded (charged the highest allowable procedural code for the visit)?  Maybe they would have charged me for a lower code worth $48.72 instead of $144.00?  Do you think?  So my question is, did they charge the highest code solely because that’s what insurance would cover, or because that’s what they thought the visit was worth?

So there was another visit I had with another doctor within the same health system.  My agreement with his office was that I was coming in for a consultation and nothing else.  I got a report from that visit and it blew me away at what I saw.  The report stated, “No cervical lymphadenopathy was noted.  Thyroid was nonpalpable. Lungs were clear bilaterally to auscultation.  Heart, regular rate and rhythm, S1, S2.  No murmers.  No CVA tenderness bilaterally.  Abdomen is soft and nontender.  Bladder is nonpalpable.”

Here’s the problem with the above statements: nobody palpated my cervical lymph nodes on that visit.  Nobody touched my neck to know whether or not my thyroid was palpable or not.  Also, nobody listened to my lungs, or my heart.  The nurse practitioner that was doing this ‘consultation’ to which I had agreed before the doctor came in didn’t even touch my abdomen, so she couldn’t have possibly known it was nontender, nor that my bladder was nonpalpable.

I didn’t like this report when I read it because it’s unethical and illegal to falsify medical records.  For them to say they did something they didn’t do is blatantly illegal.  Upon checking out, I was charged a $10 copay.  “Why?” I asked, knowing this was just a consultation.  “Becuase you have a $10 copay on office visits, sir!” the clerk rudely retorted. “That was an office visit?” I asked.  “Yep!” she said, popping her gum in my face.

As if that wasn’t bad enough, I got my explanation of benefits from Blue Cross for that visit, and they had charged me for a new patient exam!  So, apparently, I owe them even more money than my initial copay, since that was a new patient exam.

So why the unethical behavior in health care?  Is it so providers can get paid?  Is it the insurance companies’ fault?  Or how about the patients’?  Does fault lie on Big Pharma?  What about the providers?

I’m not sure.  I’m also not sure what I’m going to do?  Am I, as a health care provider, morally obligated to report something like this, or am I expected, ‘as one of us’ (which I am not) to turn a deaf ear?  I don’t know.

What would happen if Lazar Spinal Care went to a cash basis and severed all ties with insurance?  I know practice members would get better care, because I could focus on them instead of juggling patient care with trying to get paid.  Maybe I could adjust my prices so people could afford the care, even though I’m a specialist.  Would that make it work?  I will say, this is the direction we’re headed.  I don’t know when.  But I’m sure we’ll end up there.

I would love to hear your thoughts.  Please post a comment or email me at blog@lazarspinalcare.com.