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Impact of Managed Care on Quality of Care

Posted by Ed Davis, DPM on 8/29/01 at 22:39 (058408)

The medical reimbursement system, for better or worse, tends to drive a lot of practice patterns.

Managed care takes a hard statistical look at treatment outcomes and costs. The good old bell curve really is relevant when you look at treatment of any problem, plantar fasciitis included. The majority of cases will respond favorably to 'inject with cortisone and provide an orthotic.' Add in a few modalities such as night splints and a course of therapy and the 'center' of the bell curve essentially gets taken care of. The supposition is that a large number of people can get relief with a limited amount of treatment time and practitioner effort. Managed care essentially has practitioners aiming at the center of the bell curve.

Cases outside say, a couple standard deviations from the mean, are considered 'outliers.' I think that a lot of posters on this site are 'outliers.' Practice efficiencies demanded by managed care are based on allocating resources (largely practitioner time) on the bell curve center---it is better to 'cure' a large number of individuals with limited resources and tolerate failures on the 'outliers.'

Practitioners who have a large number of manged care contracts tend to practice along such patterns. It is an entity that may not be realized by the patient in need--but the practitioner will simply not allocate the additonal resources necessary and is willing to tolerate a percentage of treatment failure, not due to incompetence, lack of training or lack of knowledge but due to managed care economics. A number of HMOs have advocated residency training programs at their institutions so this mindset can be instilled in their future providers.

What about the Hippocratic Oath? There have been serious suggestions about setting it aside in light of modern economic 'realities.'

I have decided, as far as my own practice is concerned, that I need to limit the percentage of managed care contracts in order to practice in a manner that I can sleep at night, feeling that I have given all patients my best effort. It is hard to accept anything other than 'Hippocratic' medicine but the power of the manged care industry is hard to go up against.
Ed

Re: Impact of Managed Care on Quality of Care

Richard, C.Ped on 8/30/01 at 09:18 (058438)

As a pedorthic facility, we have contracts with different ppo's and other agencies such as Medicare and Medicaid. What Medicare pays for orthotics
(for diabetics only) is a joke. $68.00 for a pair of orthotics. Starting in January, it will go down to only $66.00 for a pair. Since I am a Medicare DME provider, that is what I have to take...no more.

Here is your ethics lesson. As a pedorthist, it is my job and passion to help people. I will make the same type of orthotic for my Medicare patients that I make for my insurance patients. Corners are not cut. The material is not cheap. Do I consider cutting corners because I will only make a couple of dollars? I don't think so. They receive the same treatment as anyone else. Does this perhaps cut my throat in the end? Again, I don't think so. I may not make as much on the sale as I would with something else, but as Dr. Davis stated, the treatment that I am providing makes me sleep well at night.

Granted, this is a business. We are in business to make a profit so we can pay our house payments, maternity bills and other bills. I am not in business to gouge the consumer with outrageous prices for crappy work.

I think it is sad as well as a sign of the times how people treat each other.

I may be way off the original subject..if so, I apologize. This is just a very sensitive subject with me.
Richard, C.Ped

Re: Impact of Managed Care on Quality of Care

Ed Davis, DPM on 8/30/01 at 11:59 (058465)

Richard:
Talk about a sensitive subject-- read the post in which an individual suggests that a graphite device was suggested for the profit motive of a practitioner. Offer people a better product at a reduced price and they raise the accusation of profiteering-- no wonder so many ggod people are leaving health care!
Ed

Re: Impact of Managed Care on Quality of Care

D.Thomas on 8/30/01 at 12:30 (058476)

I think I'm done on this subject. It is getting a little sensitive and I don't wnat to make anyone upset becuase I really do appreciate everyone on this board. All the doctors here are great people and I can't wait to meet Brian next month. Without Dr. Z and Dr. Davis I wouldn't have a clue on want to do next. I just want everyone to know that I appreciate your help and support through these trying times and I admit that I probably vent alot of my frustration on my doctors. It is just a very hard time in my life right now dealing with the constant pain. I just want to get better and that is what I need to focus on and drop the past. I apologize if I offended anyone or said somnething wrong, it wasn't my intention.

Re: hey, you talking about me, bud? :-)

elliott on 8/30/01 at 12:31 (058477)

I guess that was out of line for me to suggest that there may actually be a profit motive associated with orthotics.

Maybe you make less on graphite by charging less, but another might make more. Whichever the type of orthotic I was going to try, it was going to be payed out of pocket, no insurance reimbursement or forms applicable. Can I ask how much you charge your patients for graphite orthotics?

Re: hey, you talking about me, bud? :-)

Beverly on 8/30/01 at 12:45 (058479)

It is my pet peeve that insurance does not usually cover orthodics. I have good insurance... a PPO. I had no limits on PT, but orthodics are only allowed for diabetics. However, I paid out of pocket for each set of orthodics I tried and did finally find one I liked. This pair I liked cost $165.00 and was worth every penny.
Beverly

Re: hey, you talking about me, bud? :-)

Ed Davis, DPM on 8/30/01 at 13:47 (058487)

There is a profit motive associated with every service in a capitalist country--orthotics included.

The issue is whether a practitioner places profit first or patient care first. Ethical practitioners place patient care first within the constraints of making a living.

Insurance contracts vary. The cash price we charge is averages about $320. The variability comes from payment options-prepayment, delayed payment or financing.There is no difference in the fee for graphite or plastic orthotics---the patient is paying for a service with an intended therapeutic effect as opposed to a device alone. My costs from lab to lab and with variability of materials can vary with a factor up to 1.8.
Ed

Re: hey, you talking about me, bud? :-)

Ed Davis, DPM on 8/30/01 at 13:50 (058488)

Add. the above fee is for a 'functional' orthotic. Accomodative devices run $175.
Ed

Re: hey, you talking about me, bud? :-)

Ed Davis, DPM on 8/30/01 at 13:54 (058489)

Beverly:
Practitioners share your pet peeve concerning limitations in insurance reimbursement. Interestingly, patients demand more from services they are paying out of pocket. I like the idea of Medical Savings Accounts in which the patient, not the insurance company directs the health care dollars--it would level the playing field.
Ed

Re: Impact of Managed Care on Quality of Care

Richard, C.Ped on 8/30/01 at 14:20 (058491)

I love talking about sensitive subjects. Just in case anyone is wondering, I am not offended at all about what is being said...now..you talk about my new daughter...well...then it's on!!! :-)

I am not ashamed at all at what we charge for our our orthotics. We are around the $250.00 range. That ain't bad considering the national average of orthotics are around $400.00. I do discounts if someone's insurance does not cover at all, or if the patient does not have insurance. I try to treat people like I want to be treated. There is now way I could pay that out of my pocket..so I offer to split the payments to help.

Sensitive subjects...heated discussions..bring it on. That is what makes this board really fun! I miss Kim B.
Richard

Re: Impact of Managed Care on Quality of Care

BG CPed on 8/30/01 at 21:04 (058526)

I have used the same lab that Dr Davis uses for graphite. They are in my opinion the best lab out. They work they put into the device is rather complex.It is layed up by hand similar to aerospace composite. They also have great tech support that will call and ask questions. Many labs dont do that. The cost is about20% more to the practitioner than most labs charge. Good guys will use them anywy cause they want best. Bad guys will look for cheaper at the expense of patients well being

The final cost to patient is basically fixed inspite of what the practitioner pays. There are labs that make terrible devices that are no better than a premade that sell them for near the same.

Managed care has put squeeze on, some labs will actually advertise price in trade publication, as in how low they can go with no mention of quality etc. These labs appeal to weasel types. The example used about the diabetic shoe bill is a prime example. At $66 per pair he is getting hosed but he still makes them to be an upstanding guy and out of care for patients.

So then some companies will go out and brag about how 'cheap' they can provide a device that will 'squeak' by the compliance code just to fill the bill. his has been a blood trail for the sharks. Now you have in some areas IDIOTS that know nothing going around to nursing homes etc trying to get reimbursed by sticking shoes on folks when they drop off the toilet seats, walkers, and diabetic supplies.

Guess it goes back to the ethics question. One thing I have not seen mentioned is that possible due to so much lack of coverage for orthotics may make it a reason that many practitioners dont care to do a better job. If it is something that will be difficult to get paid for some may look at it like it is more trouble than it is worth and just do a 1/2 arse job. That is inexcusable but a possibility

Re: Impact of Managed Care on Quality of Care

BG CPed on 8/30/01 at 21:36 (058532)

Another aspect since I am wound up and Richard is also (must be that combative Scotsman blood) You have prices that are in a way set. The amount a insurance will pay regardless of the skill of the practitioner making them. Can you imagine if Lawyers for intance were told you can only bill $400 to handle a divorce regardless if you are Joe Schmo or F Lee Bailey do you think the quality of representation would be the same?

Managed care has the same effect. If you owned a restaurant across from the GM plant and were told you will get paid $100.000 a year to feed all of the employees whenever they came in. If you bought Steak and Lobster how long would your restaurant be open? You would have a better chance to have some money to pay your bills if you gave them mac n cheese or hotdogs.

Now say lots of folks liked to have a jello cup for desert, your nice guy you want to make them happy so you serve jello on Fridays. Now after you have paid all your bills at the end of the year some twit from resorce managment says 'you did an ok job but those little jello cups were not authorized, they cost money. I know we agreed to pay you $100.000 but we will have to take 5% off of your pay, try not to do it next year'

I bill the work comp and auto about 35% less than allowable and what they pay all day long to others. I have been getting screwed by them. I have only been paid on about 7 of the 25 I have submitted since January. Many have been billed and called more than 2 times. They say 'oh we never got a invoice , mail it again' So as of tomorrow I will raise my rate to the FULL amount since I have to spend extra time/money to chase them. See the logic? I do a better job and charge less and they screw me. Try telling them you 'didnt get the invoice' on your next insurance bill and see how they treat you.

I know I posted part of this rant a week ago, I just am geting tired and frustrated at the system and some people in it. If the politicians were worried about more than interns getting screwed they would make a reasonable reimbursment law. Maybe tell ins providers you have 15 days to pay on a claim or there will be a fee of prime rate + 3% tacked on. The technology exists. We as practitioners are giving the Ins an interest free loan. They call it 'floating' they sit on payment but are VERY efficient on the collection of premium end, why do you think that is?

I had a work comp that stiffed me due to instructions by her lawyer. I finally tracked her down, she has not worked in a year cause she stepped on a stone and 'bruised her arch' She is wearing them, says they work but wont pay because a, the insurance said they would pay for it and b, her Lawyer said she didnt have to????

Sorry about the ramble but I just wanted to give a few examples to understand what we go thru, for the Docs it is way worse. So I dont know but I do think a reasonable time to pay would be a great idea ansd easy to impliment

Re: Impact of Managed Care on Quality of Care

Ed Davis, DPM on 8/31/01 at 00:30 (058542)

I've run into just about everything you've mentioned. A lot of states have laws on the books requiring ins. companies pay claims in 30 days but rarely enforce those laws. The insurance companies just have too much political clout.

I do not see a good fix as long as third parties call the shots. The entity that we call 'health insurance' is not true insurance, it is a benefit. Insurance policies are safety nets that people hope never to use--eg. life insurance, auto insurance. What we call health insurance, on the other hand is intended for use as a corporate benefit.

Medical Savings Accounts (MSA's) put the money in the hands of the patients, not the insurance companies. It lets the patients decide how to spend their health care dollars. A patient faced with say, a $300 bill for orthotics versus $5000 for surgery will gladly pay the $300 and save a lot of pain in the process. The decision won't be insurance paid surgery versus patient paid orthotics---the playing field is leveled. MSAs are coupled with a high deductible true health insurance policy there for catastrophic expenses, that is for expenses that individuals hope never to encounter (just like auto accidents, death).
Ed

Re: Impact of Managed Care on Quality of Care

Richard, C.Ped on 8/31/01 at 09:05 (058569)

Brian,
I think you and I have conversed before about the sharks. It is kind of off subject..but I agree with you. We run into these jokers that go into dialysis centers and supply a really good diabetic shoe, but provide that crappy generic insole that comes with it (you know what I mean) and bill Medicare for it! Ahhhhhh! I have voiced my complain about this to PFA.
Richard

Re: Impact of Managed Care on Quality of Care

Richard, C.Ped on 8/31/01 at 09:06 (058570)

Amen! Preach it brother..preach it!!
Richard

Re: Impact of Managed Care on Quality of Care

Richard, C.Ped on 8/30/01 at 09:18 (058438)

As a pedorthic facility, we have contracts with different ppo's and other agencies such as Medicare and Medicaid. What Medicare pays for orthotics
(for diabetics only) is a joke. $68.00 for a pair of orthotics. Starting in January, it will go down to only $66.00 for a pair. Since I am a Medicare DME provider, that is what I have to take...no more.

Here is your ethics lesson. As a pedorthist, it is my job and passion to help people. I will make the same type of orthotic for my Medicare patients that I make for my insurance patients. Corners are not cut. The material is not cheap. Do I consider cutting corners because I will only make a couple of dollars? I don't think so. They receive the same treatment as anyone else. Does this perhaps cut my throat in the end? Again, I don't think so. I may not make as much on the sale as I would with something else, but as Dr. Davis stated, the treatment that I am providing makes me sleep well at night.

Granted, this is a business. We are in business to make a profit so we can pay our house payments, maternity bills and other bills. I am not in business to gouge the consumer with outrageous prices for crappy work.

I think it is sad as well as a sign of the times how people treat each other.

I may be way off the original subject..if so, I apologize. This is just a very sensitive subject with me.
Richard, C.Ped

Re: Impact of Managed Care on Quality of Care

Ed Davis, DPM on 8/30/01 at 11:59 (058465)

Richard:
Talk about a sensitive subject-- read the post in which an individual suggests that a graphite device was suggested for the profit motive of a practitioner. Offer people a better product at a reduced price and they raise the accusation of profiteering-- no wonder so many ggod people are leaving health care!
Ed

Re: Impact of Managed Care on Quality of Care

D.Thomas on 8/30/01 at 12:30 (058476)

I think I'm done on this subject. It is getting a little sensitive and I don't wnat to make anyone upset becuase I really do appreciate everyone on this board. All the doctors here are great people and I can't wait to meet Brian next month. Without Dr. Z and Dr. Davis I wouldn't have a clue on want to do next. I just want everyone to know that I appreciate your help and support through these trying times and I admit that I probably vent alot of my frustration on my doctors. It is just a very hard time in my life right now dealing with the constant pain. I just want to get better and that is what I need to focus on and drop the past. I apologize if I offended anyone or said somnething wrong, it wasn't my intention.

Re: hey, you talking about me, bud? :-)

elliott on 8/30/01 at 12:31 (058477)

I guess that was out of line for me to suggest that there may actually be a profit motive associated with orthotics.

Maybe you make less on graphite by charging less, but another might make more. Whichever the type of orthotic I was going to try, it was going to be payed out of pocket, no insurance reimbursement or forms applicable. Can I ask how much you charge your patients for graphite orthotics?

Re: hey, you talking about me, bud? :-)

Beverly on 8/30/01 at 12:45 (058479)

It is my pet peeve that insurance does not usually cover orthodics. I have good insurance... a PPO. I had no limits on PT, but orthodics are only allowed for diabetics. However, I paid out of pocket for each set of orthodics I tried and did finally find one I liked. This pair I liked cost $165.00 and was worth every penny.
Beverly

Re: hey, you talking about me, bud? :-)

Ed Davis, DPM on 8/30/01 at 13:47 (058487)

There is a profit motive associated with every service in a capitalist country--orthotics included.

The issue is whether a practitioner places profit first or patient care first. Ethical practitioners place patient care first within the constraints of making a living.

Insurance contracts vary. The cash price we charge is averages about $320. The variability comes from payment options-prepayment, delayed payment or financing.There is no difference in the fee for graphite or plastic orthotics---the patient is paying for a service with an intended therapeutic effect as opposed to a device alone. My costs from lab to lab and with variability of materials can vary with a factor up to 1.8.
Ed

Re: hey, you talking about me, bud? :-)

Ed Davis, DPM on 8/30/01 at 13:50 (058488)

Add. the above fee is for a 'functional' orthotic. Accomodative devices run $175.
Ed

Re: hey, you talking about me, bud? :-)

Ed Davis, DPM on 8/30/01 at 13:54 (058489)

Beverly:
Practitioners share your pet peeve concerning limitations in insurance reimbursement. Interestingly, patients demand more from services they are paying out of pocket. I like the idea of Medical Savings Accounts in which the patient, not the insurance company directs the health care dollars--it would level the playing field.
Ed

Re: Impact of Managed Care on Quality of Care

Richard, C.Ped on 8/30/01 at 14:20 (058491)

I love talking about sensitive subjects. Just in case anyone is wondering, I am not offended at all about what is being said...now..you talk about my new daughter...well...then it's on!!! :-)

I am not ashamed at all at what we charge for our our orthotics. We are around the $250.00 range. That ain't bad considering the national average of orthotics are around $400.00. I do discounts if someone's insurance does not cover at all, or if the patient does not have insurance. I try to treat people like I want to be treated. There is now way I could pay that out of my pocket..so I offer to split the payments to help.

Sensitive subjects...heated discussions..bring it on. That is what makes this board really fun! I miss Kim B.
Richard

Re: Impact of Managed Care on Quality of Care

BG CPed on 8/30/01 at 21:04 (058526)

I have used the same lab that Dr Davis uses for graphite. They are in my opinion the best lab out. They work they put into the device is rather complex.It is layed up by hand similar to aerospace composite. They also have great tech support that will call and ask questions. Many labs dont do that. The cost is about20% more to the practitioner than most labs charge. Good guys will use them anywy cause they want best. Bad guys will look for cheaper at the expense of patients well being

The final cost to patient is basically fixed inspite of what the practitioner pays. There are labs that make terrible devices that are no better than a premade that sell them for near the same.

Managed care has put squeeze on, some labs will actually advertise price in trade publication, as in how low they can go with no mention of quality etc. These labs appeal to weasel types. The example used about the diabetic shoe bill is a prime example. At $66 per pair he is getting hosed but he still makes them to be an upstanding guy and out of care for patients.

So then some companies will go out and brag about how 'cheap' they can provide a device that will 'squeak' by the compliance code just to fill the bill. his has been a blood trail for the sharks. Now you have in some areas IDIOTS that know nothing going around to nursing homes etc trying to get reimbursed by sticking shoes on folks when they drop off the toilet seats, walkers, and diabetic supplies.

Guess it goes back to the ethics question. One thing I have not seen mentioned is that possible due to so much lack of coverage for orthotics may make it a reason that many practitioners dont care to do a better job. If it is something that will be difficult to get paid for some may look at it like it is more trouble than it is worth and just do a 1/2 arse job. That is inexcusable but a possibility

Re: Impact of Managed Care on Quality of Care

BG CPed on 8/30/01 at 21:36 (058532)

Another aspect since I am wound up and Richard is also (must be that combative Scotsman blood) You have prices that are in a way set. The amount a insurance will pay regardless of the skill of the practitioner making them. Can you imagine if Lawyers for intance were told you can only bill $400 to handle a divorce regardless if you are Joe Schmo or F Lee Bailey do you think the quality of representation would be the same?

Managed care has the same effect. If you owned a restaurant across from the GM plant and were told you will get paid $100.000 a year to feed all of the employees whenever they came in. If you bought Steak and Lobster how long would your restaurant be open? You would have a better chance to have some money to pay your bills if you gave them mac n cheese or hotdogs.

Now say lots of folks liked to have a jello cup for desert, your nice guy you want to make them happy so you serve jello on Fridays. Now after you have paid all your bills at the end of the year some twit from resorce managment says 'you did an ok job but those little jello cups were not authorized, they cost money. I know we agreed to pay you $100.000 but we will have to take 5% off of your pay, try not to do it next year'

I bill the work comp and auto about 35% less than allowable and what they pay all day long to others. I have been getting screwed by them. I have only been paid on about 7 of the 25 I have submitted since January. Many have been billed and called more than 2 times. They say 'oh we never got a invoice , mail it again' So as of tomorrow I will raise my rate to the FULL amount since I have to spend extra time/money to chase them. See the logic? I do a better job and charge less and they screw me. Try telling them you 'didnt get the invoice' on your next insurance bill and see how they treat you.

I know I posted part of this rant a week ago, I just am geting tired and frustrated at the system and some people in it. If the politicians were worried about more than interns getting screwed they would make a reasonable reimbursment law. Maybe tell ins providers you have 15 days to pay on a claim or there will be a fee of prime rate + 3% tacked on. The technology exists. We as practitioners are giving the Ins an interest free loan. They call it 'floating' they sit on payment but are VERY efficient on the collection of premium end, why do you think that is?

I had a work comp that stiffed me due to instructions by her lawyer. I finally tracked her down, she has not worked in a year cause she stepped on a stone and 'bruised her arch' She is wearing them, says they work but wont pay because a, the insurance said they would pay for it and b, her Lawyer said she didnt have to????

Sorry about the ramble but I just wanted to give a few examples to understand what we go thru, for the Docs it is way worse. So I dont know but I do think a reasonable time to pay would be a great idea ansd easy to impliment

Re: Impact of Managed Care on Quality of Care

Ed Davis, DPM on 8/31/01 at 00:30 (058542)

I've run into just about everything you've mentioned. A lot of states have laws on the books requiring ins. companies pay claims in 30 days but rarely enforce those laws. The insurance companies just have too much political clout.

I do not see a good fix as long as third parties call the shots. The entity that we call 'health insurance' is not true insurance, it is a benefit. Insurance policies are safety nets that people hope never to use--eg. life insurance, auto insurance. What we call health insurance, on the other hand is intended for use as a corporate benefit.

Medical Savings Accounts (MSA's) put the money in the hands of the patients, not the insurance companies. It lets the patients decide how to spend their health care dollars. A patient faced with say, a $300 bill for orthotics versus $5000 for surgery will gladly pay the $300 and save a lot of pain in the process. The decision won't be insurance paid surgery versus patient paid orthotics---the playing field is leveled. MSAs are coupled with a high deductible true health insurance policy there for catastrophic expenses, that is for expenses that individuals hope never to encounter (just like auto accidents, death).
Ed

Re: Impact of Managed Care on Quality of Care

Richard, C.Ped on 8/31/01 at 09:05 (058569)

Brian,
I think you and I have conversed before about the sharks. It is kind of off subject..but I agree with you. We run into these jokers that go into dialysis centers and supply a really good diabetic shoe, but provide that crappy generic insole that comes with it (you know what I mean) and bill Medicare for it! Ahhhhhh! I have voiced my complain about this to PFA.
Richard

Re: Impact of Managed Care on Quality of Care

Richard, C.Ped on 8/31/01 at 09:06 (058570)

Amen! Preach it brother..preach it!!
Richard