This article is the first in a series of three regarding the healthcare system in our country, what might be called “An Rx for guaranteeing good healthcare.” I was inspired to write on this topic because I find myself, more and more, explaining to people how the system works and what is wrong with it. So many of us who are not healthcare providers learn what we know from sound bites. Few really understand the inner workings of the system, of malpractice, licensing, or the rules and regulations to which health providers are subjected. In mentioning my idea to a few people, I found that fellow health professionals thought it was a great idea, and “laypeople” as well thought it would be helpful in giving the public information. Disclaimer: obviously I want doctors to make decent livings and be respected in society, and would support things that benefit my profession. However, I also am very interested in public health and want to educate my readers in general.
Let’s call this section “Healthcare 101.” Much of the public still believes that doctors are on the higher end of the food chain where income is concerned. When I was growing up I had an uncle who was an internist, who raised his children in a six-bedroom house on Staten Island with breathtaking views. He was not a Park Avenue specialist, but rather he had a decent practice in Bay Ridge, Brooklyn, and was affiliated with a couple of run-of- the-mill hospitals. In those days people paid his bill and submitted to insurance for reimbursement. About 20 years ago all of that changed, which is part of why we have such problems in healthcare today, and why we can’t agree on what our government should or should not do to fix the system.
Let’s talk about HMOs, or those insurance plans that fell into favor at that time, where you had a “network” of doctors to choose from. You needed only to pay a small “co-pay” and the insurance company did the rest, paying the doctor the balance of the contracted fee. At that time the contracted fee was perhaps a few dollars lower than the doctor’s actual fee, but the volume generated by being part of a network panel was seen as worth the few dollars of loss. In addition, the insurance companies scared the doctors into thinking that if they did not participate they would lose patients to doctors who did. All this was fine, except that over the past 20 years those contracted fees have not gone up. Let’s say the contracted fee for a service is $50. Your co-pay is $10. The insurance company pays the doctor the remaining $40 directly. The doctor can charge $50 for that service or $500 for that service—if he is in the network, his total income is $50. The same $50 it’s been since 1990. There is no difference between a seasoned practitioner and a rookie, no difference if you have extra training or not. I have a $20,000 post-doc that took me two years to complete and that allows me to perform neuropsychological evaluations more effectively and expertly. I feel that I can charge a certain premium for such further education, but HMOs do not.
Have any of you, dear readers, gone 20 years without a raise? Or would you expect to be paid the same amount as someone with far less education or experience? In some cases the fees have actually been lowered, for example, when one plan takes over another and changes the fee structure. Along the way the consumer has become so peripheral a part of the process that many people expect to pay little, if anything, at a doctor’s visit, because the insurance company will take care of it. So, while the cost of living has increased, the “salary” paid to your healthcare provider has not. But I’m sure your premiums have increased—so who gets the money? Not me.
Here is one thing that most consumers do not know—what are considered “reasonable and customary” fees vary whether a doctor is in or out of the network. I get my full fee if I am out of the network because the patient pays it and gets reimbursed since my fees are within the realm of “reasonable and customary.” If I am in the network, referred to as a
“preferred” provider, my fee is 1/3 to 1/2 of that. So, the out-of-network fees have increased with the cost of living, but the in-network fees have not.
What else has increased? The malpractice insurance for an ob/gyn in this part of the state averages about $185,000. A neurosurgeon can easily pay over $200,000 per year. A general practitioner can spend about $35,000 on malpractice insurance. A general surgeon pays over $100,000. I only pay about $2000 per year because my license does not allow me to prescribe medications. Premiums went up about 5% in 2010. Add to this office rent, staff salaries, paying off student loans, and you can see that it takes a lot of those $50 procedures to buy the house with the breathtaking views, or ANY house for that matter. Also expect that most doctors spend about 10-14 hours a week involved in activities that are not face-to-face patient care. And while I have to keep files for seven years, there is really no statute of limitations on someone suing me, so truly, I have to keep files forever, and hope that I never have to actually use my malpractice insurance.
Let’s talk about the gate-keeping and loopholes that go on with the insurance companies. I have an intimate relationship with Melinda at Phelps Hospital as I work through my payment plan for procedures and tests that were not covered by my insurance company due to what seemed to me to be irrelevant loopholes. Mental health coverage has gotten better, particularly in New York, as we have fought for parity, and also after a young boy committed suicide when his insurance company refused to authorize any more sessions with his therapist and his parents could no longer afford to take him. When my uncle was practicing it would have been unheard of for a nameless, faceless voice on the phone to approve or deny treatment that he deemed necessary. What right does an insurance company employee have to decide that she knows my patient better than I do? How dare she authorize a hospitalization that lasts barely long enough to screw up someone’s medication regimen and then send them back out to their private therapist before the new protocol kicks in? But this is what has happened. And how about slow payment? I am right now waiting for payments from sessions I conducted nine months ago due to random reasons such as, “every claim that includes alcohol abuse is being held for review.” For nine months?
Next up: why you should be not only interested in these issues but worried as Hell…..
[blockquote class=blue]Barbara Kapetanakes, Psy.D., practices child, adult, and family psychotherapy in Sleepy Hollow.[/blockquote]