We're not in it for the money

I have a patient who occasionally e-mails me interesting articles related to healthcare. Recently he (Hi, Mr. S!) sent me an article about how doctors are nickel and diming their patients for things like filling out forms, refilling medications or giving advice over the phone:

When Jill Wolfson called the psychiatrist last year for a prescription refill for her son, she had an unpleasant surprise. Up until then, the over-the-phone refill had been free. This time, she was charged by her doctor for the service, to the tune of $25.

"I was really astounded," says Wolfson, of Santa Cruz, whose son had long been seeing this psychiatrist for attention deficit disorder. "We go in for regular checkups to get his meds looked at, so it's not like we call in for refills without ever seeing him. It just seems like it should be part of the service when you're being charged $100 an hour."

Okay, since she's being charged $100/hr, that either means she doesn't have insurance or, more likely, he doesn't accept third-party insurance, like a lot of psychiatrists. But I see her point: why charge extra for a refill?

Langston and others blame nickel-and-diming on a broken-down, outmoded system of healthcare that rewards physicians only when they have "some skin in the game," meaning face time with the patient, says Dr. Daniel Sands, an assistant professor of medicine at Harvard Medical School.

"The only kind of healthcare that is valued [by insurers] is the care delivered in the office," says Sands, who lectures on physician trends. For example, he says, doctors have been "giving away" care over the phone for years, unable to bill insurance for the time. Medical intervention by phone or e-mail, he says, is time-consuming, requires solid medical judgment, carries the usual malpractice risks - and is completely uncompensated.

Here is another perspective on rising health care costs, and who has to pay:

Many patients are lumping doctors in with insurance providers and pharmaceutical companies as greedy components of the escalating heath-care crisis, but in many ways, doctors are simply struggling to keep their practices afloat. Rising overhead costs, lower reimbursement amounts from insurance providers and delays in receiving payments due to haggling over bills, among other things, have put considerable pressure on them.

"The burden of running the health-care system has been shifted over to physicians," said Daymon Doss, CEO of the Petaluma Health Care District. "Insurance companies have created very complex billing systems that often deny reimbursement for services. So, doctors and their staffs have had to become very skillful at filling out forms."

Despite the financial burdens and dangers, there are still some of us who swim salmon-like against the healthcare system stream:

Some physicians, such as Petaluma primary-care doctor Eric Holmberg at 108 Lynch Creek Way, prefer solo practice, despite the mounting obstacles. He returned to a solo private practice more than two years ago.

"In a large, clinical-practice setting, patients are juggled between physicians and nurse practitioners, so doctors don't get to know patients very well," he said. "As a solo physician, I am able to provide better, more personal care. I don't try to run a lot of people through my office."

That's what medical micropractices are all about.

Holmberg has had to run a very tight ship, though.

"I've kept my overhead expenses as low as possible, partly by cutting down my staff to one employee, who serves as a medical assistant and front-office worker," he said. "If I had the financial capacity, I would hire another person."

I know what Dr. Holmberg is talking about. I have been trying to manage a solo medical practice on my own for the past 2 1/2 years, and while I have enjoyed the freedom of spending as much time as I need to in a visit with a patient, it has been a struggle for me to get paid for the work I do. Therefore this week I finally hired someone to help me with the medical billing and chasing down denied or "forgotten" payments from insurance companies.

So if you think you are paying too much for health care and aren't getting your money's worth, you're absolutely right:

For the fifth year running, Blue Cross of California has spent less than 80 percent of premium dollars on patient care, according to a report released by the California Medical Association.

Blue Cross, the state's largest for-profit health insurer, spent 78.9 percent of its premium dollars on patient care in fiscal year 2004-2005, with 21 percent to profits and administration, according to CMA's 13th annual report examining annual health plan expenditures.

"Vital patient care is being short-changed by for-profit HMOs that send ever increasing portions of premium to Wall Street instead of spending it on patients," said Michael Sexton, M.D., CMA president. "If a substantial part of these profits were kept in the health care system, it would help make Californians healthier, stabilize the endangered emergency care system and ensure that all patients get access to the care they expect and deserve."

So where is the money going?

Wellpoint Health Networks, the parent company of Blue Cross of California, paid CEO Larry Glasscock more than $5.4 million in salary and other compensation. Thomas Snead Jr., another Wellpoint executive, received more than $5 million in compensation. Neither figure includes stock option amounts or values. These compensation amounts were several million dollars more than the average compensations earned by other health plan executives.

Last year, WellPoint reported that CEO Leonard Schaeffer received more than $11 million in total stock, salary and other compensation.

You know, $11 million could pay for a lot of school forms and medication refills, not to mention childhood immunizations and cancer screening tests.

It's gotten so bad that doctors have to resort to doing things like this ("Boost productivity? Walk less") as a way to make more money. Money that is often needed for a practice to survive.

Anyways, like most doctors so far, I do not charge extra for filling out forms, answering questions by e-mail or refilling medications over the phone. But that could change in the future, depending on what changes come about in physician reimbursement from insurance plans. Even so, it's not about getting rich. I just want to be able to make a living doing something that can help others.

If I really went into medicine to make money, I could've done something like this.