Just what is the difference anyway?

"Cheerful Pickle" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

Hi, gang,

I just got back from my dermatologist's office and I have
a question (not involving any specifics as to my case
though I will refer to it solely for illustrative
purposes).

On his wall was a letter from my HMO's Chief of
Dermatology apologizing

for

Quoted message said:

the long waits in getting appointments for dermatologists.
It seems there is a worldwide shortage of general
dermatologists. Part of the reason is an aging population
requires dermatologists more. Part is that many
dermatologists are older and retiring. The letter noted
that, for instance, in the UK, they expect to lose half of
their dermatologists within the next five years. The third
reason puzzles me. It seems that many general
dermatologists are abandoning their specialty for one
called "cosmetic dermatology."

Wait a minute. We are dealing with the skin here. All skin
conditions of which I am aware involve in their cluster of
symptoms things like pimples, scaling, flaking, blemishes,
dandruff, the skin turning strange colors, etc. I remember
the first time I saw a dermatologist twenty one years

ago.

Quoted message said:

It was for cosmetic reasons. The diagnosis was basal cell
skin cancer. After eleven years of either being not
diagnosed or misdiagnosed by family doctors (one crazy
doctor actually thought it was asthma), I finally knew
what it was. Later basal cell cancers did not concern me
since the first one never became life threatening. I
simply had them removed for cosmetic reasons. The only
time I was at the dermatologist for noncosmetic reasons
(though it started out as being for cosmetic reasons) was
for melanoma. Once that diagnosis was made, my concern
switched from cosmetics to survival. That was seven years
ago and I am still here.

Besides melanoma, some skin conditions might cause people
to seek a dermatologist for noncosmetic reasons, such as
itching, but I suspect most conditions concern the patient
mostly for cosmetic reasons. That leads to the question
(finally): Just what is the difference between general
dermatology and cosmetic dermatology anyway, since it
would seem that most dermatological problems manifest
themselves cosmetically?

Cosmetic dermatology addresses aging/damaged skin and
includes chemical peels, botox, laser wrinkle removing and
other laser treatments, and a wide variety of other
treatments that aren't medically necessary, but desired by
the large baby boomer patient base. It is cosmetic in
nature and not aimed at treating skin cancers, rashes etc.
Even liposuction is part of many cosmetic dermatology
training programs.

Cosmetic dermatologic treatments are generally not covered
by insurance since they are cosmetic and it is the insurance
company that determines whether or not the procedure is
cosmetic. As a result, these treatments are, for the most
part, strictly cash-on-the-barrelhead and they have patients
standing in line anxious to pay the fee. This represents a
much more financially productive use of the dermatologists
time given the extremely poor Medicare and third-party
insurance reimbursements for a standard dermatology office
visit. Few dermatologists these days want to spend their
days treating rashes at $15 per office visit gross
reimbursement. At the rate they are reimbursed, it's very
difficult to make a dermatology practice financially viable.
Reimbursements are going down rapidly and government-imposed
expenses are going up, not to mention malpractice insurance.

In many or most cases, even private physicians are forced to
contract with insurance companies for what's called
"negotiated fee-for-service" reimbursement contracts. A key
feature of these contracts is that the physician cannot balance-
bill the patient for a covered service - has to accept what
the insurance company decides to pay. By declaring one's
practice limited to "cosmetic dermatology" the dermatologist
takes him/herself out of the third party arena altogether
and eliminates the financially disadvantageous situation of
treating rashes all day for pennies.

It's a sign of the times. The same thing is happening in
other specialties as well, and is likely to increase.
Insurance companies are really changing the landscape of
doctor availability and distribution.

HMc

Howard McCollister said:

This represents a much more financially productive use of
the dermatologists time given the extremely poor Medicare
and third-party insurance reimbursements for a standard
dermatology office visit. Few dermatologists these days
want to spend their days treating rashes at $15 per office
visit gross reimbursement. At the rate they are
reimbursed, it's very difficult to make a dermatology
practice financially viable. Reimbursements are going down
rapidly and government-imposed expenses are going up, not
to mention malpractice insurance.

Hi, Howard,

That was fast. Thanks.

Anyway, if things are as bad as you say regarding
financial reimbursements, then it is a wonder that anyone
would want to be any kind of doctor. It would also seem
that the insurance companies and the HMO's are in
desperate need of regulation. Paying tiny amounts for
services and charging sky high premiums for patients is a
recipe for sky high profits.

However, that makes me wonder. If I were not signed up with
a group plan through my NONPROFIT HMO, then I would be
charged $450 a month with a $1000 a year deductable. They
say they are paying their doctors a competitive rate, which
I assume would be your $15 an hour. Few people would go
through about a dozen years of higher education for $15 an
hour. As I said, high premiums and low payments has to
spell high profits, even for a nonprofit HMO. That does not
sound right.

Even in a group (Medicare) I still have to fork out an
additional $90 a month to my HMO for their services, besides
whatever Medicare pays them.

I don't know. Something simply does not sound right with
your scenario.

Of course, those insurance plans that cover prescriptions
(of course, mine does not) have to pay out extra because of
noncompetitive pricing by pharmaceutical companies who know
they have people over the barrel with their drug pusher
prices for medicines without which a person is either dead
or in serious medical trouble. I have heard of some
prescriptions that cost $25 to $30 a pill or higher. It
seems that is where some good, old-fashioned price controls
or something is needed, as is done in so many other
countries from Canada to India to New Zealand. However, that
is a topic for a different thread.

--
Andy Rugg - The Cheerful Pickle To email me, please remove
"postheap" from my email address. Thanks.

In article <[email hidden]>,

Howard McCollister said:

Cosmetic dermatology addresses aging/damaged skin and
includes chemical peels, botox, laser wrinkle removing and
other laser treatments, and a wide variety of other
treatments that aren't medically necessary, but desired by
the large baby boomer patient base. It is cosmetic in
nature and not aimed at treating skin cancers, rashes etc.
Even liposuction is part of many cosmetic dermatology
training programs.

Cosmetic dermatologic treatments are generally not covered
by insurance since they are cosmetic and it is the
insurance company that determines whether or not the
procedure is cosmetic. As a result, these treatments are,
for the most part, strictly cash-on-the-barrelhead and
they have patients standing in line anxious to pay the
fee. This represents a much more financially productive
use of the dermatologists time given the extremely poor
Medicare and third-party insurance reimbursements for a
standard dermatology office visit. Few dermatologists
these days want to spend their days treating rashes at $15
per office visit gross reimbursement. At the rate they are
reimbursed, it's very difficult to make a dermatology
practice financially viable. Reimbursements are going down
rapidly and government-imposed expenses are going up, not
to mention malpractice insurance.

In many or most cases, even private physicians are forced
to contract with insurance companies for what's called
"negotiated fee-for-service" reimbursement contracts. A
key feature of these contracts is that the physician
cannot balance-bill the patient for a covered service -
has to accept what the insurance company decides to pay.
By declaring one's practice limited to "cosmetic
dermatology" the dermatologist takes him/herself out of
the third party arena altogether and eliminates the
financially disadvantageous situation of treating rashes
all day for pennies.

It's a sign of the times. The same thing is happening in
other specialties as well, and is likely to increase.
Insurance companies are really changing the landscape of
doctor availability and distribution.

Hmmm. Cosmetic cardiology? Cosmetic neurosurgery? Could be
interesting.

Cheerful Pickle said:

Howard McCollister said:

This represents a much more financially productive use
of the dermatologists time given the extremely poor
Medicare and third-party insurance reimbursements for a
standard dermatology office visit. Few dermatologists
these days want to spend their days treating rashes at
$15 per office visit gross reimbursement. At the rate
they are reimbursed, it's very difficult to make a
dermatology practice financially viable. Reimbursements
are going down rapidly and government-imposed expenses
are going up, not to mention malpractice insurance.

Hi, Howard,

That was fast. Thanks.

Anyway, if things are as bad as you say regarding
financial reimbursements, then it is a wonder that anyone
would want to be any kind of doctor. It would also seem
that the insurance companies and the HMO's are in
desperate need of regulation. Paying tiny amounts for
services and charging sky high premiums for patients is a
recipe for sky high profits.

However, that makes me wonder. If I were not signed up
with a group plan through my NONPROFIT HMO, then I would
be charged $450 a month with a $1000 a year deductable.
They say they are paying their doctors a competitive rate,
which I assume would be your $15 an hour. Few people would
go through about a dozen years of higher education for $15
an hour. As I said, high premiums and low payments has to
spell high profits, even for a nonprofit HMO. That does
not sound right.

Even in a group (Medicare) I still have to fork out an
additional $90 a month to my HMO for their services,
besides whatever Medicare pays them.

I don't know. Something simply does not sound right with
your scenario.

Of course, those insurance plans that cover prescriptions
(of course, mine does not) have to pay out extra because
of noncompetitive pricing by pharmaceutical companies who
know they have people over the barrel with their drug
pusher prices for medicines without which a person is
either dead or in serious medical trouble. I have heard of
some prescriptions that cost $25 to $30 a pill or higher.
It seems that is where some good, old-fashioned price
controls or something is needed, as is done in so many
other countries from Canada to India to New Zealand.
However, that is a topic for a different thread.

--
Andy Rugg - The Cheerful Pickle To email me, please remove
"postheap" from my email address. Thanks.

There are ways for offices to make money with managed
care, but it certainly doesn't foster the Marcus Welby
model of practice. In some areas, disruptions and
inequities of supply/demand force esp. younger doctors
onto these plans in order to survive. By the same token,
if you are in an area dominated by one or a few large
employers, doctors are effectively forced to fall in
line or move. Of course, this is a part of the
marketplace. What I personally find offensive is the HMO
concept as it applies to contract doctors' offices (not
in self-contained facilities with salaried staff and
doctors). It basically takes the insurance risk away
from the insurance companies where it belongs and puts
it onto the doctor, who cannot go hat in hand to the
state insurance department for redress.

Steve

--
Mark & Steven Bornfeld DDS
Brooklyn, NY
718-258-5001
dentaltwins.comdentaltwins.comOpen ↗

"Cheerful Pickle" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

However, that makes me wonder. If I were not signed up
with a group plan through my NONPROFIT HMO, then I would
be charged $450 a month with a

$1000

Quoted message said:

a year deductable. They say they are paying their doctors
a competitive rate, which I assume would be your $15 an
hour. Few people would go through about a dozen years of
higher education for $15 an hour. As I said, high premiums
and low payments has to spell high profits, even for a
nonprofit HMO. That does not sound right.

Even in a group (Medicare) I still have to fork out an
additional $90 a month to my HMO for their services,
besides whatever Medicare pays them.

I don't know. Something simply does not sound right with
your scenario.

First of all, it's $15 for an office visit, figure 30-50
office vistis per day. And of course that's not all they do
- they might do procedures such as removing basal cell skin
cancers or mole removals which reimburse higher. As to your
HMO, they equalize by cost-shifting. Their surgeons, who
generate more revenue for the HMO, get paid less so that the
dermatologists can get paid more.

You asked who'd do all of that for such low reimbursement.
The answer is: fewer and fewer every year.

By the way, see if you can find out how much the CEO of your
HMO gets paid.

HMc

George Tirebiter said:

Quoted message said:

It's a sign of the times. The same thing is happening in
other specialties as well, and is likely to increase.
Insurance companies are really changing the landscape of
doctor availability and distribution.

Hmmm. Cosmetic cardiology? Cosmetic neurosurgery? Could be
interesting.

Retainer practices (a.k.a. "boutique" practices) where
patients pay an annual fee (ranging from a few hundred to a
few thousand dollars) in exchange for services not typically
provided by the average private practice or HMO clinic, are
an up-and-coming thing in primary care. As long as costs
continue to rise and reimbursement continues to fall, you're
going to see more and more physicians in every specialty
doing creative things to enable them to opt out of the
insurance game.

Cheerful Pickle said:

Of course, those insurance plans that cover prescriptions
(of course, mine does not) have to pay out extra because
of noncompetitive pricing by pharmaceutical companies who
know they have people over the barrel with their drug
pusher prices for medicines without which a person is
either dead or in serious medical trouble. I have heard of
some prescriptions that cost $25 to $30 a pill or higher.
It seems that is where some good, old-fashioned price
controls or something is needed, as is done in so many
other countries from Canada to India to New Zealand.
However, that is a topic for a different thread.

OK...let's change the subject. :-)

Prescription drug costs. Obviously too high, in many cases.
What to do? Well, most of us know that it costs lots and
lots of money for drug companies to successfuly develop and
eventually market a drug. However, there is a great deal of
waste in the system, and pricing resembles a used-car lot
when it comes to the deals struck with insurance companies
and pharmacy benefit managers (PBMs). Drug companies already
enjoy several years of patent life, during which generic
competitors cannot be produced. This gives them a nice
window of opportunity to recoup their investment, IMHO.

What I propose is a few simple changes to eliminate waste,
confusion, and pricing inequities. First, eliminate direct
to consumer (DTC) advertising (TV commercials, etc.) Drugs
are not consumer products. Drug advertising at the consumer
level is confusing and misleading. In many cases, it leads
patients to demand expensive brand-name drugs when less
expensive generic alternatives are available, and in other
cases, the long litany of potential side effects featured at
the tail-end of many of these commercials may frighten
patients into discontinuing their medication. Don't get me
wrong; I am not in any way suggesting that the public should
be kept in the dark about drug availabily or side effect
potential. However, I do not believe that advertising media
and the slanted picture they present are the best avenue for
communicating this information. it's also horrendously
expensive, and I feel that this money would be better saved
in order to lower the price of the drugs themselves.

Second, mandate uniform wholesale and retail drug pricing.
Every insurance company and PBM pays the same wholesale
price for a given drug. All pharmacies buy (wholesale) and
sell (retail) a given drug for the same price. If a drug
company wants to lower its price in order to get onto an
insurance company formulary, then they must make their drug
available to every other company for the same price. In this
way, there will be much less need for physicians and
patients to keep up with multiple formularies (which are
usually based solely on the cost of the drugs to each
particular company, regardless of what the insurance
companies and PBMs say to the contrary), as uniform pricing
will eliminate much of the variability in terms of preferred
drugs. Drug companies will also be incented more to lower
their prices in order to remain competitive, as they will no
longer be able to work "under the table" deals for
preferential formulary inclusion.

Mark & Steven Bornfeld DDS said:

Of course, this is a part of the marketplace. What I
personally find offensive is the HMO concept as it
applies to contract doctors' offices (not in self-
contained facilities with salaried staff and doctors).
It basically takes the insurance risk away from the
insurance companies where it belongs and puts it onto
the doctor, who cannot go hat in hand to the state
insurance department for redress.

I'm glad that most of my HMO doctors are salaried employees
of the HMO, therefore not tempted to pad prices with
unnecessary procedures. It is only for a small handful of
not commonly used specialties for which Group Health
Cooperative farms out work. That is the way an HMO should
run, if you ask me, since it removes from doctors any
financial temptation for all those unnecessary procedures
that tend to inflate insurance premiums and permit covering
more procedures that are really medically necessary, but
often not always covered by many plans. Some tort reform
would also help as long as doctors and HMO's are forced by
predatory shark lawyers to conduct often expensive and
medically unnecessary tests that only an attorney would
appreciate.

--
Andy Rugg - The Cheerful Pickle To email me, please remove
"postheap" from my email address. Thanks.

TPFKAA said:

Retainer practices (a.k.a. "boutique" practices) where
patients pay an annual fee (ranging from a few hundred to
a few thousand dollars) in exchange for services not
typically provided by the average private practice or HMO
clinic, are an up-and-coming thing in primary care. As
long as costs continue to rise and reimbursement continues
to fall, you're going to see more and more physicians in
every specialty doing creative things to enable them to
opt out of the insurance game.

Of course, anything to screw those on fixed incomes, the
working poor, the lower middle class and all other who
cannot afford to pay this doctor, that doctor and the other
doctor a retainer for designer services for things he may or
may not need in the future. Boy, in that case, why don't
doctors simply go out and buy their own insurance company?
That's what your idea sound like in many ways.

For instance, I make $900 a month on a disability pension.
How am I going to afford designer services such as you
envision? That illustrates exactly what is wrong with the
current screwball medicine for profit system that this
country has evolved.

If, on the other hand, you only referred to those things
that no insurance company or HMO in its right mind should
cover such as vanity cosmetic surgery (as opposed to
reconstructive cosmetic surgery) and worthless procedures
and practices such as homeopathy, where the "prescribe"
marginally useful (at best) concoctions then water them
down so much so as to make them clinically useless. Neither
one benefits anyone in any real medical way, but then, in
that case, I guess that is OK. Why should I, as an HMO
consumer, for instance, want to subsidize someone who has a
sort of Munchhausen's Syndrome for cosmetic surgery making
them want to be charter members of the Surgery of the Month
Club. Let them pay for their own weird psychological
hangups. Otherwise, there should be none of your designer
prepaid services.

The only serious concern I have with the restrictions both
insurance companies and HMO's have is in the case of
expensive experimental procedures and medicines. On the one
hand, I can see why no one (including myself) would be
eager to fund unproved and risky experimental surgery (such
as Dr. DeBakey's first artificial heart). Prepaid retainers
for experimental surgery does not sound workable at all.
I'm not sure what the answer is in this case. Perhaps
someone smarter than I does. On the other hand, I just do
not believe that such procedures should be restricted to
the Bill Gates' of this world because insurance does not
cover them and
99.999% of the people cannot afford them.

I will not even get into some of the totally idiotic
insurance rules regarding necessary prescriptions dreamed up
by warped bean counters. However, even that is somewhat
understandable because of the appalling greed of the
pharmaceutical companies who use pricing policies borrowed
from heroin and cocaine pushers to rip people off.

By the way, doctor, don't tell anyone, but it is a pleasure
corresponding with you. This has been one of the most
stimulating threads I have ever been involved in. Thanks.

--
Andy Rugg - The Cheerful Pickle To email me, please remove
"postheap" from my email address. Thanks.

TPFKAA said:

rescription drug costs. Obviously too high, in many cases.
What to do? Well, most of us know that it costs lots and
lots of money for drug companies to successfuly develop
and eventually market a drug. However, there is a great
deal of waste in the system, and pricing resembles a used-
car lot when it comes to the deals struck with insurance
companies and pharmacy benefit managers (PBMs). Drug
companies already enjoy several years of patent life,
during which generic competitors cannot be produced. This
gives them a nice window of opportunity to recoup their
investment, IMHO.

Hi, TPFKAA,

Since you chose to change the subject, let me comment about
what you said. While it is true that it costs a bundle,
sometimes just barely ten digits, to make a new prescription
ready for market, that is not the whole story. That is what
the pharmaceutical companies would want you to believe. In
most cases, even with foreign pharmaceutical companies,
Uncle Sam (translate that you and I) end up forking out 85%
or so of the cost of development for these overprices pills.
Additional funding for these costly government mandated drug
tests can often come from organizations dealing with the
disease the drug is supposed to treat (such as cancer
societies, heart societies, Tourette's Syndrome societies,
fibromyalgia societies, etc.). Though these pale in
comparison to the government's contribution, they do further
lower the actual cost to the drug pushers. (I use that term
deliberately, since they seem to use the same logic in
setting prices as do heroin pushers -- screw the customer
since they have you in a position where you are hooked on a
given drug, whether it is a opium derivative, an anti-organ
rejection drug or an anti-HIV drug.

Taking all that into account, if you have an average of a
million customers a month, it does not take a rocket
scientist to figure out that the cost of development should
not require doubling or tripling the cost of a pill. You
know that happens. All too often, as soon as the patent
(translate that monopoly) expires and the drug company has
to charge competitive prices, the price drops by half to two-
thirds. With a million customers, for instance, all a drug
company would have to charge would be an extra $10 a month
to recoup their actual cost of development in only fifteen
months -- but they keep up those sky high prices for the
dozen years or so left on their patent.

I am not sure if I can agree with your idea for uniform and
fixed pricing. Joe's Pharmacy, for instance, would only buy
a only a very few bottles of Protonix a month (an overpriced
placebo, if you ask me), for instance, while Kaiser
Permenente and Group Health Cooperative (who combine their
purchasing power to lower their costs) probably buy quite a
few cases of it a month. This is the principle of "cheaper
by the dozen, cheaper still by the million," and is a normal
business practice in almost all industries. You certainly do
not expect WalMart to pay the same price for Coca Cola as
does Kathy's Korner Market; why expect a major purchaser of
a drug to pay the same price as does some pharmacy that only
buys two bottles a month. The last I heard, druggists buy
their pills. If the insurance company had to buy the
prescription for the druggist and then get it to whatever
druggist needs it, it would take quite a bit longer than
twenty minutes to get a prescription filled. My HMO, taking
advantage of their mass purchasing power already charge all
their customers who have to pay for their own pills about
the same for their drugs that seniors will get with their
discount cards starting next month from regular pharmacies,
such as Safeway, Walgreens or Eckhard. Therefore, they will
not offer those cards.

By the way, I have been totally opposed to the idea of
direct marketing of prescriptions to patients by television
or any other means. It inflates the prices, as you say, and
I also hear that almost everyday some doctors have waste
their valuable time to explain to some patient that the
"Purple Pill" is not for headaches. That is, if they can
tell me whether the "Purple Pill" is Prilosec or Nexium,
since I have heard both referred to by that name. How is
that for confusion?

--
Andy Rugg - The Cheerful Pickle To email me, please remove
"postheap" from my email address. Thanks.

Cheerful Pickle said:

I'm glad that most of my HMO doctors are salaried
employees of the HMO, therefore not tempted to pad prices
with unnecessary procedures.

News flash: your McDoctor is under constant and increasing
pressure to keep costs under control (read: to do as little
as possible) by their HMO *employers* (yes, the insurance
companies who sign their paychecks). Conflict of interest?
You betcha.

Quoted message said:

unnecessary procedures that tend to inflate insurance
premiums and permit covering more procedures that are
really medically necessary, but often not always covered
by many plans.

Here's another news flash for you. Just because some
insurance company says something isn't covered, doesn't
mean it's "not medically necessary." Blue-sky it all you
want, but your insurance company is only in it for the
money. The less care they provide to you, the more money
they make for them.

Quoted message said:

Some tort reform would also help as long as doctors and
HMO's are forced by predatory shark lawyers to conduct
often expensive and medically unnecessary tests that only
an attorney would appreciate.

And more and more HMOs are being successfully sued for
withholding medically necessary testing and treatment.

Cheerful Pickle said:

TPFKAA said:

Retainer practices (a.k.a. "boutique" practices) where
patients pay an annual fee (ranging from a few hundred
to a few thousand dollars) in exchange for services not
typically provided by the average private practice or
HMO clinic, are an up-and-coming thing in primary care.
As long as costs continue to rise and reimbursement
continues to fall, you're going to see more and more
physicians in every specialty doing creative things to
enable them to opt out of the insurance game.

Of course, anything to screw those on fixed incomes, the
working poor, the lower middle class and all other who
cannot afford to pay this doctor, that doctor and the
other doctor a retainer for designer services for things
he may or may not need in the future. Boy, in that case,
why don't doctors simply go out and buy their own
insurance company? That's what your idea sound like in
many ways.

I can understand your feeling. But giving ideal one-on-
one individualized attention at the fee levels of
managed care is not practical. For one thing, most
patients would never get an appointment. The whole
system is set up for high-volume. On the one hand, some
of the services of "boutique" practices are luxuries,
not necessities. On the other, many doctors prefer to
practice on a model of individualized care and feel
entitled to be paid at a level these sevices deserve.
Everyone could have boutique care--but it would have to
be paid for--by someone. If there was the will to pay
these fees, the schools would crank out enough graduates
to fill the need. If no one wants to pay, if they wish
to pay for medical care as a commodity and not a
dedicated, individual service, that's what people are
going to get. There are a few saints who will be willing
to go to school many years, continue training in
residencies for additional years, incur huge debts, and
work in a regulated environment where the fees are set
by other people and give the kind of individualized care
some of the boutiques aim for, but you'll never get
enough to do the job--unless the money is there.

Steve

Quoted message said:

For instance, I make $900 a month on a disability pension.
How am I going to afford designer services such as you
envision? That illustrates exactly what is wrong with the
current screwball medicine for profit system that this
country has evolved.

If, on the other hand, you only referred to those things
that no insurance company or HMO in its right mind should
cover such as vanity cosmetic surgery (as opposed to
reconstructive cosmetic surgery) and worthless procedures
and practices such as homeopathy, where the "prescribe"
marginally useful (at best) concoctions then water them
down so much so as to make them clinically useless.
Neither one benefits anyone in any real medical way, but
then, in that case, I guess that is OK. Why should I, as
an HMO consumer, for instance, want to subsidize someone
who has a sort of Munchhausen's Syndrome for cosmetic
surgery making them want to be charter members of the
Surgery of the Month Club. Let them pay for their own
weird psychological hangups. Otherwise, there should be
none of your designer prepaid services.

The only serious concern I have with the restrictions both
insurance companies and HMO's have is in the case of
expensive experimental procedures and medicines. On the
one hand, I can see why no one (including myself) would be
eager to fund unproved and risky experimental surgery
(such as Dr. DeBakey's first artificial heart). Prepaid
retainers for experimental surgery does not sound workable
at all. I'm not sure what the answer is in this case.
Perhaps someone smarter than I does. On the other hand, I
just do not believe that such procedures should be
restricted to the Bill Gates' of this world because
insurance does not cover them and
99.999% of the people cannot afford them.

I will not even get into some of the totally idiotic
insurance rules regarding necessary prescriptions dreamed
up by warped bean counters. However, even that is somewhat
understandable because of the appalling greed of the
pharmaceutical companies who use pricing policies borrowed
from heroin and cocaine pushers to rip people off.

By the way, doctor, don't tell anyone, but it is a
pleasure corresponding with you. This has been one of
the most stimulating threads I have ever been involved
in. Thanks.

--
Andy Rugg - The Cheerful Pickle To email me, please remove
"postheap" from my email address. Thanks.

--
Mark & Steven Bornfeld DDS
Brooklyn, NY
718-258-5001
dentaltwins.comdentaltwins.comOpen ↗

On 2004-05-06 16:41:17 -0400, Cheerful Pickle
<[email hidden]> said:

I seem to have hit a nerve. ;-)

Quoted message said:

Of course, anything to screw those on fixed incomes, the
working poor, the lower middle class and all other who
cannot afford to pay

The concept of a retainer practice is quite controversial,
particularly among doctors who actually understand the
economics involved. Clearly, it is *not* the solution for
everyone, particularly the groups of people you mentioned.
However, consider this. With declining reimbursements and
escalating costs, many physicians will be forced out of
business entirely, to relocate, to abandon high-risk
procedures (like delivering babies), and to stop accepting
patients with lowball insurance payers like Medicare and
Medicaid. This is *already* happening. If things don't
change, it will only get worse.

In my opinion, we need to change the laws that restrict
physicians from charging patients a fair price for our
services. Many patients are *willing* to pay, but are
legally prevented from doing so by Medicare laws and
insurance contracts. If this were changed, these patients
could indirectly subsidize the "charity care" that every
doctor *wants* to provide, but is increasingly unable to
provide simply because there's no way in the current
insurance reimbursement environment to do the necessary cost-
shifting. This is the same other professions, including the
legal system, are able to do "pro bono" work. Believe me,
they're not really doing it "for free". Somebody else is
paying for it, indirectly.

Quoted message said:

By the way, doctor, don't tell anyone, but it is a
pleasure corresponding with you. This has been one of
the most stimulating threads I have ever been involved
in. Thanks.

You're welcome. 🙂

Cheerful Pickle said:

I am not sure if I can agree with your idea for uniform
and fixed pricing. Joe's Pharmacy, for instance, would
only buy a only a very few bottles of Protonix a month (an
overpriced placebo, if you ask me), for instance, while
Kaiser Permenente and Group Health Cooperative (who
combine their purchasing power to lower their costs)
probably buy quite a few cases of it a month. This is the
principle of "cheaper by the dozen, cheaper still by the
million," and is a normal business practice in almost all
industries. You certainly do not expect WalMart to pay the
same price for Coca Cola as does Kathy's Korner Market

Wal-Mart's pricing policies are predatory. I don't know how
much you know about how Wal-Mart does business, but there
are a lot of skeletons in their closet. This isn't something
I think we need to emulate in healthcare. Unfortunately, we
already have (read: PBMs).

Quoted message said:

why expect a major purchaser of a drug to pay the same
price as does some pharmacy that only buys two bottles
a month.

Because it would help make prescription drugs more
affordable to all.

Quoted message said:

The last I heard, druggists buy their pills. If the
insurance company had to buy the prescription for the
druggist and then get it to whatever druggist needs it, it
would take quite a bit longer than twenty minutes to get a
prescription filled.

Huh? Pharmacies fill prescriptions from stock. I'm not sure
what you're talking about here. The death of small
pharmacies is truly a crime, which has been perpetrated by
large PBMs in the name of the almighty dollar. It's Wal-
Mart, but on a much more dangerous level.

TPFKAA said:

On 2004-05-05 19:45:06 -0400, Cheerful Pickle <cheerfulpickle@net-

venture.compostheap said:

I'm glad that most of my HMO doctors are salaried
employees of the HMO, therefore not tempted to pad prices
with unnecessary procedures.

News flash: your McDoctor is under constant and increasing
pressure to keep costs under control (read: to do as
little as possible) by their HMO *employers* (yes, the
insurance companies who sign their paychecks). Conflict of
interest? You betcha.

About 25 years ago I worked part time in a dental
office that was under contract to some capitation
plans. The boss took me aside and told me, "We get
$40/year for these patients. If they have one or two
cavities, fill them. If they have more, fill the
deep ones."

Steve

Quoted message said:

Quoted message said:

unnecessary procedures that tend to inflate insurance
premiums and permit covering more procedures that are
really medically necessary, but often not always covered
by many plans.

Here's another news flash for you. Just because some
insurance company says something isn't covered, doesn't
mean it's "not medically necessary." Blue-sky it all you
want, but your insurance company is only in it for the
money. The less care they provide to you, the more money
they make for them.

Quoted message said:

Some tort reform would also help as long as doctors and
HMO's are forced by predatory shark lawyers to conduct
often expensive and medically unnecessary tests that only
an attorney would appreciate.

And more and more HMOs are being successfully sued for
withholding medically necessary testing and treatment.

TPFKAA said:

News flash: your McDoctor is under constant and increasing
pressure to keep costs under control (read: to do as
little as possible) by their HMO employers (yes, the
insurance companies who sign their paychecks). Conflict of
interest? You betcha.

Hi, TPFKAA,

NEWS FLASH: not all HMO's are insurance companies. I would
never sign up for an HMO owned by a for profit insurance
company. That is courting the type of problem of which you
speak. Some HMO's, like mine, are non-profit organizations
owned by its membership and run by a board elected by its
patients and doctors. Conflict of interest? I think not.
Doctors in private practice are the ones with a real
conflict of interest. All too often, instead of doing things
in the patient's best interest, they do procedures solely to
improve their bottom line. A cardiac surgeon, for instance,
makes several times more money for a double bypass surgery
than for a double angioplasty. If he is watching his bottom
line, he will try to talk you into the procedure that makes
more money for him, even if it puts you at more risk. Fifty
years ago, the tonsillectomy my pediatrician inflicted on me
(without anesthesia) was probably unnecessary, but popular
back then among pediatricians as a money maker. That is the
price people pay when doctors are paid more for each
procedure, rather than being paid a fixed salary. As to who
looks over the shoulders of my doctors, it is not bean
counters but the doctors who are their department heads.
What is wrong with that kind of accountability.

--
Andy Rugg - The Cheerful Pickle To email me, please remove
"postheap" from my email address. Thanks.

TPFKAA said:

In my opinion, we need to change the laws that restrict
physicians from charging patients a fair price for our
services.

And another thing...

I'm a good doctor. Why should I get the same lousy fees as
the quack down the street? Only in medicine. Well, that can
change too. I recommend that insurance companies reward
physicians who focus on quality, who install electronic
medical record systems (EMRs), and can demonstrate that they
are achieving certain thresholds with respect to objective
health measures. For example, if, by using my EMR, I can
demonstrate that 80% of my diabetics have HbAIc values below
7%, that 80% of my patients with high cholesterol have
reached their target lipid levels, that 80% of my
hypertensive patients have reached their blood pressure
goals, then I should be paid at a higher level than the guy
who's seeing a zillion patients a day, but doing a terrible
job taking care of them.

Technology is making this possible. The biggest problem now
is figuring out how to pay for the technology.

TPFKAA said:

On 2004-05-07 01:52:15 -0400, Cheerful Pickle <cheerfulpickle@net-

venture.compostheap said:

I am not sure if I can agree with your idea for uniform
and fixed pricing. Joe's Pharmacy, for instance, would
only buy a only a very few bottles of Protonix a month
(an overpriced placebo, if you ask me), for instance,
while Kaiser Permenente and Group Health Cooperative
(who combine their purchasing power to lower their
costs) probably buy quite a few cases of it a month.
This is the principle of "cheaper by the dozen, cheaper
still by the million," and is a normal business practice
in almost all industries. You certainly do not expect
WalMart to pay the same price for Coca Cola as does
Kathy's Korner Market

Wal-Mart's pricing policies are predatory. I don't know
how much you know about how Wal-Mart does business, but
there are a lot of skeletons in their closet. This isn't
something I think we need to emulate in healthcare.
Unfortunately, we already have (read: PBMs).

Quoted message said:

why expect a major purchaser of a drug to pay the same
price as does some pharmacy that only buys two bottles
a month.

Because it would help make prescription drugs more
affordable to all.

Quoted message said:

The last I heard, druggists buy their pills. If the
insurance company had to buy the prescription for the
druggist and then get it to whatever druggist needs it,
it would take quite a bit longer than twenty minutes to
get a prescription filled.

Huh? Pharmacies fill prescriptions from stock. I'm not
sure what you're talking about here. The death of small
pharmacies is truly a crime, which has been perpetrated by
large PBMs in the name of the almighty dollar. It's Wal-
Mart, but on a much more dangerous level.

Very few people are aware of this danger. In fact,
I don't have a solid understanding of how the
system works, but it does sound terribly dangerous
to me too.

Steve

Cheerful Pickle said:

NEWS FLASH: not all HMO's are insurance companies. I
would never sign up for an HMO owned by a for profit
insurance company.

I believe you're in a small minority of people who have a
choice in the matter. Most get whatever their employer
gives them.

From an historical perspective, medical insurance in
general, and employer-provided insurance in particular, are
the things that led to the weird state of affairs where
medicine is in this limbo between capitalism and socialism.

Few people view medical care as their own financial
responsibility as they once did, but most doctors still have
to operate on a capitalist model. Few patients would be
paying for higher priced procedures if they had to foot the
bill themselves, and therefore there probably wouldn't be a
new procedure to choose at all since the incentive to
develop it never would have existed in the first place.

All in all, it's a weird, screwed up system in a state of
flux and I don't think there are any simple answers.