No PayDay Loan Needed!

Photographs Courtesy of Renee Rendler-Kaplan

I love American ingenuity. There is always somebody ready to capitalize on somebody else’s misery.

First, thanks for the many kind words from people who had no idea about the “hamster on a wheel” life of a primary care doctor. I discussed how difficult primary care doctors (internists, pediatricians, family practitioners) are finding it to make a living (I am still waiting for that 10 % pay raise from President Obama. I find it hard to believe that is going to solve the primary care crisis!).

I had to laugh though, when I got a “friendly” comment (AKA Smam) telling me that I qualified for a payday loan.

“$1500 Cash Payday pickup Cash Wired to Your Bank in 1 Hour Apply, E-Sign, and Get Cash Today”

Ha! Free money!!!??? Thanks, you made my day. Laughter is always therapeutic (except during an IRS audit, I guess). I could make more money if I knew how to do internet advertising/spam (which I would, of course, never be ethically willing to do).

Last updated May 1, 2010 by Dr. Vee

Uh Uh Tomorrow is Payday

Photograph Courtesy of Bob Cuthill

Tomorrow is payday and that is difficult in the life of a primary care physician (I’m not trying to get you to feel sorry for me, just trying to explain the realities of being a primary care doctor in 2010).  Can’t make payroll tomorrow.  This has become a frequent occurrence over the past two years as reimbursements have decreased and the number of patients that need to be seen daily has increased.  

The next time you get frustrated with your primary care doctor (not necessarily the case for some specialists, who are reimbursed at much higher rates) because you don’t have enough time with them, and you have had to wait for a long time in the Waiting Room, remember:  Primary Care doctors have to see more patients in a shorter period of time to keep the practice open. 

Medicare, Blue Cross and other companies audit doctors who routinely see (and therefore bill) for longer office visits.  United Healthcare used to routinely, unilaterally, downcode my office visits from higher to lower levels.  They underwent class action suit and had to stop that practice.  In the end, remember that insurance companies want profits (How else can the CEO make $25 million dollars?) and one method is less reimbursement for doctors. 

But doctors are really rich, don’t work hard and make a lot of money, right?  Put yourself in my place.  If you sacrificed your twenties and thirties hanging out 48 hrs at a time in hospitals taking care of incredibly sick patients, would you be willing to earn less than many nurses, podiatrists, dentists and nurse practitioners?  Ask yourself honestly.  Do you expect to be paid for your time?  Or do you work at Wal-Mart for free?  Do you get free food at the grocery store (Ok, food stamps don’t count–hopefully at least your kids get to eat with the food stamps).  How about free gasoline for your car? How about a free car because you are a nice person and don’t want to get paid for working as a waitress. Hmm…you mean you do want to get paid?  And you work harder than doctors?  And how about those hundreds of thousands of dollars in student loans you accumulated trying to become a waitress.  Probably don’t need to pay those back right? 

And when you go to the grocery store, you get free food, right (OK, food stamps for your kids don’t count.  It is important for your kids to eat).  And free gas for your BMW, right?  And your mortgage is free, too, right? 

Anyway, my point is that everyone deserves to be paid for working hard, and should be able to repay their hundreds of thousands of dollars of school loans (My family isn’t wealthy).  I don’t want to pay to be a doctor, which happens frequently. I have to “lend” my office money when I can’t make payroll.  Problem is, I “lent” the office $6000 last week to pay for the credit card bill with vaccines, medical supplies (know how much that table paper and gloves cost???) and my malpractice insurance.  So now I don’t have anything left to “lend” my practice.  And three people who work with me in the office also depend on me to feed their families.  Never thought this is what life as a doctor would be like. 

So the answer has to be see more patients, less time, not fair to patients or to me.  But the way it is in the primary care world.  Oh, and I have tried praying.  A LOT. 


Last updated April 25, 2010 by Dr. Vee

What an Exhausting Day!

Photograph of Stethoscope Courtesy of Neil Kad

Wow, Busy Monday, with lots of sick people from the weekend needing to be seen.  Patient with hip fracture in the hospital and healthy girl newborn–both doing well!  Reminds me how exhausting it is to listen and really try to help twenty two to twenty five patients a day.  Sometimes their problems are so overwhelming, I come home and feel like my brain can no longer process more information!    But lucky I get to do this every day!

Last updated by Dr.Vee on May 10, 2010

A Foreign Language: The Medical Billing System


I can sum up the biggest problem with the health care system in one word: bureaucracy.  The regulations that doctors have to memorize, in addition to plain old medicine (which in my experience is complex enough!) looks like the indecipherable ingredients on the back of a processed food bag: CPT/ICD codes, HIPPA compliance, Red Flag rules, CMS oversight, meaningful use of EMRS, prescription drug plan overrides, pre-authorization, high fructose corn syrup, red dye #3 and MSG.  Both MSG and physician regulations give me a major headache, and leave me with less energy to give to my patients (That’s why I blog!! To relieve stress!!)

I have spent years trying to learn the French language and suddenly figured out that I did not need to learn French when I was already fluent in another foreign language:  medical billing. 

Over a quarter of my overhead as a primary care physician goes toward paying for staff, software, transmission companies and other costs related solely to medical billing.  I frequently get resumes from billing clerks in other fields who think that because they did billing for an auto parts store or a plumber, they can get paid even better doing medical billing.  These billers believing erroneously that all physicians do is send a bill to the patient and get paid large sums of money by expending minimal effort.

The fundamental belief held by Medicare, Medicaid and other other insurance companies is that physicians will not be honest in their billing practices.  That is the reason the physician must code for an office visit, procedure or surgery using the right modifiers, codes and service locations in the right boxes of the form (called the HCFA form) to prove that he or she did not commit fraud and abuse.  Next the doctor has to pay for an electronic system to submit the form containing all the diagnoses and level of service.  Finally the doctor then has to pay for another service to transmit all the claims to the right insurance company.  The insurance companies are counting on our ignorance and hope that doctors will do what they typically do:  give up and just not bill.  I know that I, and most physicians, underbill the level of care of an office visit so that they don’t get audited by Medicare or other insurance companies.

An office visit can be rejected (not considered a “clean claim”) if the physician’s NPI number, Medicare numbers and the ICD and CPT codes are not just right.  Certain numbers (which is always a mystery to the doctor and billers) have to go in certain boxes, or else the the claim is rejected. 

Trying to call Medicare or an insurance company to ask a question about a claim takes several hours.  If you call Medicare back (and assuming you actually get through–make sure you have a couple of free hours on your hands to wait on hold), you will get a different answer from a different claims specialist. 

The key to all this complexity is very simple: doctors don’t understand the system and will often give up and just write off the office visit.  That saves the the insurance company or Medicare a bundle.  

I am not sure why coding the diagnosis hypertension to the most specific decimal point makes a bit of difference in the time and complexity of the care I provided to a patient.  Does my level of care make a difference if the patient has hypertension with kidney disease versus hypertension with heart disease?  Since they are equally complex patients, why does Medicare want me to distinguish their diagnoses? And why penalize me if I just bill using plain old hypertension, not otherwised specified (NOS)?   And why does Medicare have to know if the blood pressure is controlled or not controlled?  Do I or the patient get bonus points if the patient eliminates salt from his diet and gets his blood pressure controlled? 

Actually, some day doctors will be penalized for their patients have uncontrolled diabetes or cholesterol. I am not sure why I should be responsible for a patient who does not eat healthy or exercise, but the government is set on “outcomes” and “pay for performance,” which means that those patients who are non-compliant will not have doctors who are willing to take care of them.

Conversely, a patient may have underlying complex hypertension, but, if the blood pressure is controlled, I will spend less time on that medical problem and bill a lower level office visit.  So why does the detailedness of the diagnosis code (“to the highest specificity”) make a difference?  

Why make the doctor and billing specialist (and believe me, this person has to be a specialist) spend the extra time to put two decimal points on a diagnosis code that is of no relevance to the patient’s care?  Would it not make sense to spend the doctor and the staff”s time teaching patients about a no added salt diet to control hypertension rather than figuring out the right hypertension code to the highest specificity?  Like there isn’t any waste in the medical system there? 

Even more confusing is the fact that every year certain CPT and ICD codes and diagnoses are eliminated or converted to different codes.  That means every year the doctor has to buy new books and learn about new codes to the highest decimal point specificity, or risk having claims rejected.  Why do codes have to be changed from year to year?  The patient with hypertension and kidney disease still has the same ailment, but little did he know that his diagnosis code has changed! 

For example, if the diagnosis code for uncontrolled (“Malignant”) hypertension is changed, and I don’t want to spend $600 to buy coding books that particular year (I won’t be able to afford to buy them next year–that is the absolute truth) that tells me you have changed the diagnosis code and I use the old diagnosis code, why is my claim denied?  Have I not provided the same service to the patient, whether the high blood pressure is controlled, uncontrolled, two decimal points, one decimal point, with kidney disease (further broken down into kidney disease stages one through five),  has salad dressing on the side and a partridge in a pear tree?

I have looked in coding books frequently, trying to find a code for what my patient has.  The books themselves are mazes and not set up the step by step way doctors think.  If you look under “Disease” multiple completely unrelated diseases of many different organ systems are listed.  How would one know to even look in that section? Furthermore, there are diagnoses for illnesses that I know do not actually exist. Many codes are “V” codes or represent preventive medicine issues, which are not paid for by most insurance companies, including Medicare.  So why list them?   Somebody was actually paid to make up those diagnoses and assign codes to them.  Such a waste of manpower.

The rules of the coding system involving medical decision making, physical exam bullet points and past medical/social/family history are so complex that coders and doctors can’t possibly agree with the level of service that can be billed. For example, I can bill a higher level office visit if I ask the  patient about her family history.  Maybe that is a poor use of time if I am already aware of the family history or if the family history is irrelevant to the patient’s medical condition.  Either way, it doesn’t matter, because I can bill a higher level visit if I ask and document the family history in my note.  Some doctors learn to play the billing game well, which does not mean they provide better medical services.   Their billers just know how to bill more effectively.

President Obama claims there is so much fraud and abuse in the medical system that eliminating it will pay for a new health care system.  I believe the fraud and abuse are in the unnecessary bureaucracy utilized to ensure all the complex rules of billing are followed.  If changes in the health care system require more bureaucrats to carry out the system, then the point of changing the system to save money has been lost.

So many health care dollars would be saved if a straightforward  billing system were in place.  Patients should be furious that this money, which could be put to use to expand services to more patients, instead is being spent on bureaucrats who exist simply to make sure that the doctor is learning and using the foreign (billing) language correctly. 

Literally millions of dollars could be saved if so many people did not exist simply to monitor the doctor, with the underlying assumption that doctors by nature must be corrupt and require this type of oversight.  That money is better spent towards actual health care, not health care billing.

Last Updated by Dr. Vee on May 2, 2010

Health Care Reform by Increasing Primary Care Physician Salaries (Yes, a Necessary Evil)

Here are some thoughts by primary care internists and pediatricians.  Individual physician names have been removed (except NEJM article author)

Fixing primary care is critical to health care reform but will require simultaneously fixing several problems, including those related to remuneration, the work environment, and medical education.1 The most critical of these issues is remuneration.

The week of June 15 to 26, 2009, was bittersweet for those of us who care about primary care. President Barack Obama addressed the American Medical Association, emphasizing the central role that primary care must play in health care reform.2

We then learned of the death of Dr. Lynn Carmichael, a founder of the modern field of family medicine.3 The roller coaster continued with the publication in the Journal of two articles about the crisis in primary care, detailing the moribund state of primary care4 and the policies proposed for resuscitating it.1

I believe that these proposed policy reforms are doomed to fail, because they ignore the impact of managed care on remuneration. Primary care was supposed to be paramount under managed care. “We need you to be gate keepers,” we were told, “and we’ll pay you well to perform that service.”

In actuality, remuneration for primary care decreased under managed care, as contracts were negotiated solely on the basis of cost. Continuity of care was disrupted, as managed care relegated primary care doctors to ambulatory settings, replaced them with nurse practitioners or physician assistants, and utilized hospitalists for inpatient care.

Worse, patient panels were dissolved and reassembled annually during open enrollment, as companies negotiated not with doctors, but with employers.

So how can we fix the problem? Why not simply mandate that all payers, public or private, pay a capitation fee or salary designed to assure that primary care doctors can achieve a professional standard of living? In exchange, primary care doctors would provide continuing, comprehensive primary care (including night call and preventive services) for a reasonably sized panel of patients.

For the sake of discussion, I would suggest a salary and fringe benefit package of about $300,000 per year (in 2009 dollars) to care for 2000 patients, ($150 per patient), with incentives for special circumstances (e.g., working in underserved communities) or special services (e.g., delivering babies). All other fees, deductibles, and copayments would be waived. The problem of physician-generated demand would be eliminated, which would radically reduce costs to insurers. Billing would disappear. Patients would have open access to their primary care physicians.

Freed from the constraints of billing for the traditional encounter, primary care doctors could employ innovative methods to deliver primary care, including the Internet and group encounters.

Arthur M. Fournier, M.D. University of Miami Leonard Miller School of Medicine Miami, FL This article (10.1056/NEJMopv0907129) was published on August 19, 2009, at

References Bodenheimer T, Grumbach K, Berenson RA. A lifeline for primary care. N Engl J Med 2009;360:2693-2696. [Free Full Text] President Barack Obama addresses the American Medical Association, Chicago, July 15, 2009. (Accessed August 13, 2009, at

 Brecher EJ. Dr. Lynn Paul Carmichael dies at 80: pioneered family medicine at UM. Miami Herald. June 23, 2009. (Accessed August 13, 2009, at

Steinbrook R. Easing the shortage in adult primary care — is it all about money? N Engl J Med 2009;360:2696-2699. [Free Full Text]

Comments by other Physicians:

The operating word here is salary. On average 50% to 60% of insurance payments and copays go towards covering the office overhead. I would be more than happy with a salary including fringe so long as the overhead of my office is covered in addition to this payment. Too often when these plans are put together small details are missed and then, what was designed to help becomes a major headache to us.  (written by a pediatrician).

 Primary Care Remuneration — A Simple Fix Date: Fri, 21 Aug 2009 11:06:24 -0400 This is very good suggestion and an alternate to a Single Payer. However something would have to be in place to assure that managed care would not be shifting patients. Obviously there would be no need for them to cherry pick. Also over all cost to the system should be easier to predict.  (written by another pediatrician).

Last updated September 7, 2009 by Dr. Vee

Universal Health Care and the Crisis in Primary Care

I am moderating a Town Hall Meeting on Healthcare on June 14, 2009.  Lots of opinions, lots of controversy.   We all know the health care system is broken, and too costly.  We just don’t have the perfect solution.

Many studies show that improving access to primary care will prevent many serious illnesses such as heart disese and cancer.  Primary care physicians are also on the front lines to coordinate care among specialists, to make sure that duplicate studies are being done, and that the patient is collaborating in his or her plan of care.  

Pediatricians and other primary care physicians promote vaccinations, which prevent many serious illnesses.  Do you want to depend on your heart doctor to advise you about colon cancer screening or your stomach doctor to discuss the shingles vaccine? 

Specialists play a valuable role in the health care system.  They just can’t substitute for primary care physicians.  Primary care is critical to prevent serious illnesses and contain health care costs.

But most primary care physicians face decreasing reimbursements from Medicare and Medicaid, and increasing regulations from commercial insurances.   So why does the insurance company try to limit what it calls “unnecessary” medical care by requiring administrative forms and phone calls to be completed by physicians to obtain CAT scans and brand name medicines?  Who benefits, the patient or the insurance company? Did you know that the CEOs of Aetna, UnitedHealthcare and Blue Cross Blue Shield get paid over 20 million dollars per year? And I am guessing that the CEOs get as many CAT scans, MRIs and brand name medications they want. 

Many experts argue that universal health care will result in a two tiered medical system like in Europe and Canada.  Patients (e.g. CEOs of big companies and politicians) who have the resources get top-of-the-line-cost-is-of no-issue medical care, while many other patients have long waits for access to basic medical services that we do routinely daily here in America. 

There is a serious lack of morale among primary care physicians.  Many of them have had to retire early or close their doors because they cannot make ends meet doing primary care.  Sure some of them adapt and inject restylane or do laser hair removal, but there is only so much hair in the world.  Once all the hair and spider veins have been zapped, primary care physicians will be hard pressed to find procedures that yield adequate compensation.  Certainly counseling patients during office and hospital visits about diabetes, lifestyle changes and smoking cessation, which prevent so many illnesses, is poorly reimbursed compared to high dollar procedures such as heart surgery and stomach bypass surgery.  Wouldn’t it be better to live in a culture in the country where health and wellness is promoted to PREVENT costly procedures that are required when patients become ill?

The current model of health care pays for treatment of illnesses over the prevention of illnesses.  Procedures are compensated at a significantly higher rate than health counseling and the treatment of chronic illnesses such as asthma, high blood pressure and diabetes.  I am NOT arguing that we should do away with lifesaving procedures.  But we cannot sustain our current health care model where 10 % of patients make up 90% of health care expenditures.  And most of that money is spent in the last year of life.  Many times, patients are kept on ventilators despite clear evidence that they have terminal illnesses that are not reversible.  When a patient has a massive heart attack or stroke and cannot tell you that the last thing he wants is to die on a ventilator in an ICU of a hospital, the health care system must continue to do expensive, futile treatment.

The average American is not sympathetic to the concerns of primary care physicians, because it is believed that primary care doctors earn too much anyway.  So that is why only 2% of medical school graduates go into primary care.   They prefer to enter higher paying specialties, especially in light of the fact that the average medical student graduates with $140, 000 of debt. 

If America wants to maintain a high intellectual level to it’s primary care  work force, then primary care physicians must be fairly compensated for their time (including coordination of care) and intellectual care such as counseling patients on health maintenance.  There is no way around it.  Medical students and residents will not go into primary care, and primary care physicians will continue to go out of business if reimbursements are not increased.  

Of course, the trend currently is to have primary care be carried out by nurse practitioners and physicians assistants.  Just remember, there is a HUGE difference in the time and depth a physician trains vs. a nurse practitioner or physicians assistant’s training.  I am afraid for America if primary care is taken out of the hands of doctors, due to expense, and put in the hand of unsupervised allied health practitioners.  Certainly physicians assisstants and nurse practitioners play a vital role in health care.  But they do not SUBSTITUTE for a physician.

We all believe that universal health care will ultimately decrease health care expenditures.  But the question is who will pay for universal health care?  Raise taxes?  Or pay for the uninsured in hidden ways such as increased hospital charges and health insurance charges for patients who do have insurance.  We all pay for the uninsured, and we pay for it in the most costly way:  emergency room care and hospitalizations.

One of the lessons learned from Massachusetts is that if everyone has health care insurance, there aren’t enough primary care doctors to meet the demand!  I know there will be dissenting views from nurse practitioners, patients and politicians.  Let me know what you think. 

And if you appreciate your primary care physician, tell him or her!  A kind word goes along way to improve the morale of primary care physicians, and reminds them that they went into primary care to make a difference in the lives of their patients, not to learn how to fill out insurance forms!

Dr. Vee

Last updated June 8, 2009 by Dr. Vee