Spin Doctor Reflux

I’ve often written about Spin Doctors. How they work for health insurance carriers and pharmaceutical companies to put a positive spin on all the nasty things that they do.

It occurred to me that the Medical Profession could use some positive spin themselves. After all, people tend to be uncomfortable with health care providers because of the nasty things that they say and do. So why don’t Doctors start putting a positive spin on different diseases, medical procedures and other terminology?

For example. Let’s take Diabetes. Everyone dreads hearing the following words coming out of their Doctor’s mouth:

“Mr. Jones, your blood work came back. I’m afraid that you are diabetic. We are going to have to start you on a series of medications and a restricted diet in order to determine what steps are needed in order to get your blood sugar levels into the normal range.”

Yuk. No wonder why people hate going to the doctor. So instead of calling the disease ‘diabetes’, why not start calling it being ‘too sweet’ instead? Technically correct, and a hell of a lot less scary to hear. Here’s the same thing after the medical Spin Doctoring:

“Aw, Mr. Jones, you are just too sweet! What ARE we going to do with you?”

As a further enhancement, this diagnosis could be delivered by a cute young female doctor, with a nice Southern accent. Who wouldn’t want to hear that?

Here are some other Spin Doctored medical terms, before and after:



==========================================================
Colonoscopy = Heiny Spelunking
==========================================================
Before:

“Mr. Jones, it’s time that we schedule you a colonoscopy”

After:

“Mr. Jones, who’s up for for some Heiny Spelunking this weekend?”


==========================================================
Endoscopy = Belly-Telly
==========================================================

Before:

“Mr. Jones, we need to examine your stomach lining and duodenum for ulcers amd polyps. Please call the surgical center to schedule an endoscopy”

After:

“Smile Mr. Jones – you’re going to be on Belly Telly!”


Get the picture? Now, let’s try stringing a bunch together…

==========================================================
Genital Warts = Love Bumps
Cauterization = Sizzler
General Anesthesia = Happyville
Catheter = Auto-Tinkler
==========================================================

Before:

“Mrs. Jones, those lesions appear to be Genital Warts. In fact, they are the worst case that I have ever encountered. I’m afraid that your best option at this juncture is cauterization. This is a surgical procedure that will require general anesthesia. Post surgery, to prevent complications, we will need to insert a catheter into your uretha”


After:

“Mrs. Jones, you got the love bumps! Let’s go to the Sizzler in Happyville and get you an Auto-Tinkler!”

Wow! This is easy and fun to do! I never realized James Carville has such an simple job!

Here are some other terms, pre and post Spin Doctoring:


==========================================================
Frontal Lobotomy = Making Nice-Nice

Incision = Boo-Boo

Amputation = 10% off

Rhinoplasty = Anti-Streisand

Castration - Ken Job

Craniotomy - Pop Top

Electroshock Therapy - Catching a Buzz

Gastric Bypass - Jenny Craig Special

Liposuction - Weight-Washers
==========================================================


I’ve got a bunch more for my next post. You can play too! Comment me some suggestions and I will include them next time.

Have fun!


***** Found this Interesting, Entertaining or Informative? Please read the complete blog at: *****
http://healthcarehullabalo.blogspot.com/

Free Blog Counter

I've Got a Secret!

If a doctor wants to get his ir her bills paid by a carrier, they must know all of the secret codes to use. Think I am kidding? Well, maybe just a little…

The truth is a doctor can’t just bill an insurance company by saying “The patient has the flu – I examined her and gave her a good going over – you owe $75 for the office visit.”. No, the doctor must submit special codes to the insurance carrier that tell the carrier what was wrong and what he did to fix it.

These codes, developed and published by the AMA, fall into 2 distinct types: ICD (International Classification of Disease) or diagnosis codes specify what is wrong with the patient. CPT (Current Procedural Terminology) specifies what was done to the patient.

Actually, these codes are a great idea. They allow medicine to become more objective, and thereby allow real statistical data to be gathered and compiled on different diseases. Like most things, in life, the devil is in the details…

Insurance carriers use these codes to deny valid claims whenever they can. The doctor must use the proper CPT code with the proper ICD code, or risk not getting the insurance claim paid. There is enough vagrancy within the code system so that the carriers have enough ‘wiggle room’ to deny a valid claim. There are ‘modifiers’ or 2 digit codes that are added to the end of a 5 digit CPT code that give more specific details about that particular procedure. Some carriers require as many as 3 additional modifier codes attached to each procedure code. What makes matters worse, the coding rules can vary from carrier to carrier, or even between different plans from the same carrier. And these requirements constantly change. If the doctor does not follow these rules, they risk lower payments from the carrier, or even denial or the claim altogether. In the worse case scenario, doctors are accused of ‘insurance fraud’ if they use the wrong code or modifier – even when the doctor has decided that those codes best described that particular patient encounter. This has created an entire industry of ‘coding’ newsletters and seminars. Most offices spend thousands of dollars each year on coding manuals and staff training, just to stay on top of the coding shell game. Larger practices will have at least one person whose job is to ensure proper coding

One of the largest players in the coding game is a company call Ingenix. Ingenix has an entire series of coding manuals that are updated each year. A complete set of these manuals cost several thousand dollars. Part of this set is a ‘Fee Analyzer’ that shows doctors what other physicians in their area and specialty charge for each procedure code (Doctors are not permitted by law to discuss their fees directly with each other). Ingenix also publishes the same type of data for use by insurance carriers to aid them in determining what to pay doctors for each procedure. The interesting thing is that these two Ingenix data sets have little to no correlation.

It’s also interesting to note that Ingenix is owned by the UnitedHealth Group, that also owns United Healthcare, one of the largest health insurance carriers in the country. So, basically, we have doctor’s paying significant sums of money to a company that tells them what they can charge an insurance company for their services. And that company is owned by an insurance company. Talk about letting the fox guard the chicken coop…






***** Found this Interesting, Entertaining or Informative? Please read the complete blog at: *****
http://healthcarehullabalo.blogspot.com/


Free Blog Counter

European Vacation

Actually, this didn’t happen to me, but it did happen to some friends of mine.

Their son was playing in a pick-up game of basketball, when he was knocked over by a player on the other team. He fell, and got a good knock on the head. No biggie.

Later that day, he was having headaches, that may or may not have been the result of the earlier injury. Being prudent people, his parents took him to the Emergency Room just to be safe – they know that when it comes to closed head injuries, you never want to take a chance.

Well, they held him in the ER for a few hours and observed him. A doctor or 2 stopped by to talk with him. He was even sent for a CAT scan to make certain that his brain was not bleeding or swelling (all the right things to do) After 3 hours in the ER, and with a clean CAT scan, he was pronounced clear of any life-threatening head injury and discharged. Total bill for these 3 hours - $5700.00

Wow. When you think about it, that’s enough to take a family of 4 on a nice cruise. Or buy a reliable used car. Or do lots of other fun things. Of course, being well insured, they had to pay only a 10% co-pay – enough for a nice weekend away.

Don’t get me wrong – they did the right thing by getting their son checked out after his head knock – but WHY does an ER visit cost nearly $6,000.00, especially when 95% of that time was spent just waiting around? Total time spent with a health care professional amounted to about 30 minutes. According to Payscale.com, at the high end of the pay scale, an ER physician gets paid about $140.00 an hour. Nurses and assistants, of course, get paid even less. Let’s be generous here and say that the total personnel costs (doctors, nurses, technicians, administrators, janitors, etc.) cost the hospital $500.00. Kick in a couple of hundred for supplies, etc. This means that the rest of the money, some $5,000.00 went towards running the CAT scan machine and using the facility for a few hours. On paper, at least, it sounds like hospitals are making money faster then the US Mint. Yet, most hospitals are crying the fiscal blues, and many of them are closing their doors as they are no longer fiscally viable.

Something is very, very wrong here….

Very, very wrong ....


***** Found this Interesting, Entertaining or Informative? Please read the complete blog at: *****
http://healthcarehullabalo.blogspot.com/


Free Blog Counter

Around the World in 80 Minutes

Today I took a little tour around the world, courtesy of my health care carrier.

I picked up a prescription today, and I was told that my co-pay was $35.00. Practicing what I preach, I asked the pharmacist “How much would that cost me if I didn’t have insurance?” I was told it would have cost me $35.99.

What the hell, I thought, let me call my carrier and see if this is a mistake. And so began my ‘World Tour’. I picked up my phone, and dialed the 800 number on my ID Card…little did I realize that my phone would instantly become my own personal magic carpet, instantly transporting me all around this blue marble….




First stop: Exotic India. I spent a good 30 minutes on the phone with a very nice lady.

It would have been shorter, but she couldn’t understand my New Jersey accent and I couldn’t understand her New Dehli one. She patiently explained that, according to my plan, the prescription fell into the $35 co-pay category. But, I protested, why am I paying close to $2,000 a month for health care coverage when all I am saving is 99 cents? Oh, that’s a different department. Let me give you another 800 number. Someone at that office will be sure to assist you….

Next Stop: Southwestern US. Since my new Indian friend couldn’t answer the 99 cent question (she “wasn’t trained for that”), she transferred me to the ‘Group Health Service Center’, located somewhere in the great Southwest.


Here, another very nice person told me that my new Indian friend should have answered my question and that she should have never transferred me to her department. Her department doesn’t handle that. My new Southwestern lady friend couldn’t help me, but she seemed to genuinely feel bad about my situation. I guess even cowgirls do get the blues. She gave me another 800 number and told me to “ask for a supervisor”.


Next Stop: Back to New Dehli: Here I made another new Indian friend, who had a better command of the Queen’s English.


Unfortunately, she couldn’t answer my 99 cent question, either. I would have to discuss this with my employer. Well, I explained, I’m self employed. Does my plan cover mental health? You know, just in case someone catches me talking to myself and decides to commit me for a psychological evaluation. She didn’t know how to answer this, so I followed the advice of my new cowgirl friend and politely asked to speak with her supervisor. Unfortunately, he wasn’t available. (He probably auditioned for the Indian version of ‘Who Wants to be a Millionairre” and was busy being tortured by the police). With no other options, she regretfully informed me that she was sari but I would have to speak with someone in ‘Corporate’…. She gave me yet another 800 number to call. These people ladled out 800 numbers like vindaloo at an all you can eat buffet. I said my goodbyes to my other new Indian friend, and bid a fond farewell to the Indian subcontinent….

Last Stop: The Nutmeg State: Here, at long last, I had the good fortune to speak with a nice gentleman from the Corporate HQ in Connecticut. Surely he would have an answer to the 99 cent question!



And he did! After ‘looking into it’, he told me that my pre-packaged prescription was for a 90 day supply, and that I should have paid a $105.00 co-pay for the $35.99 retail package. Before he could ask me for the extra $70, I quickly hung up the phone and ended my globetrotting sojourn.

And so concluded my round the world adventure. My travels took me a little over an hour to complete. I can’t wait to tell my story back at the Reform Club in old Londontown.







Suck it, Phileas Fogg



***** Found this Interesting, Entertaining or Informative? Please read the complete blog at: *****
http://healthcarehullabalo.blogspot.com/

Free Blog Counter

The Jerk

Well EXCUUUUSSSSEE MEEEEE!

Apparently, I got it wrong. My last post lambasting executive compensation at Horizon BC/BS of NJ was apparently off-base. Well, according to Horizon’s Spin Doctors, it was.

Shortly after Horizon’s executive compensation packages for 2009 were announced earlier this year, Horizon’s Spin Doctors went into high gear with a email blast that attempted to control the damage. You see, there was a a very good reason why these executives were paid so well even though the company did so poorly. Actually, there were several ‘good’ reasons. Did their explanations hold water? You be the judge…

Explanation Part 1: Part of that increase, according to the report, came from deferred compensation from previous years...

===> Oh, so why was his compensation deferred? It couldn’t have anything to do with Horizon’s attempt to convert to a for-profit company in those years? You weren’t just cooking the books to make Horizon look more profitable, I hope. Is it just a coincidence that, when Horizon puts this effort on hold, the deferred compensation is dispersed all at once?





Explanation Part 2: Marino had declined numerous salary and bonus increases that were due to him since 2005.

===> What a Guy! I’m just glad that someone was finally able to convince him to take the money.





Explanation Part 3: Horizon’s executive salaries are in line with the rest of the industry.

===> Great! We’re not the only ones getting ripped off! Misery does love company!





Explanation Part 4: Total executive compensation at Horizon BCBSNJ equates to 64¢ per member, per month or $7.68 per member, per year in annual premiums costs. This represents 0.24% of our members’ monthly premiums;

===> By my math, this means that your average monthly premium is just $267.00. WOW! Can I get on that plan? Please? Pretty please? Or could you just introduce me to one person who pays this premium? I’d like to shake their hand!




Explanation Part 5: In 2009, 88.9 cents of every premium dollar went directly towards paying medical costs for our members.

===> So, with $5.1 billion collected in premiums in 2009, you spent 11.1% or 561 million dollars on operating costs. That blimp must burn a lot of gas!




My last question is, of that 561 million, how much was spent on Spin Doctors? I hope you compensated them well…these guys are GOOD!


***** Found this Interesting, Entertaining or Informative? Please read the complete blog at: *****
http://healthcarehullabalo.blogspot.com/


Free Blog Counter

King Kong

Let’s face it …most of us have been feeling a financial pinch over the last few years. Rising prices, a high jobless rate, real estate and stock markets in free fall. It hasn’t been easy for most Americans.

Even people working for our health insurance carriers are not immune. Last summer, Horizon Blue Cross and Blue Shield (New Jerseys largest health insurance carrier) laid off hundreds of employees, including many who were with the company for 20 years or longer. Those workers who retained their jobs are now working even longer hours for the same pay, as they try in vain to make up for the reduction in the work force. As a business, Horizon indicated a loss of $946,370 in 2009 on revenue from premiums of $5.1 billion. It seems that Horizon workers are feeling the economic pinch just like the rest of us.

Well, most of them, anyway.



According to a recent article in the Asbury Park Press, the president and CEO of Horizon received a 59% pay hike in 2009, taking home a cool $8.7 million in salary and benefits. This broke down to a salary of $934,615 and a bonus of nearly $7.8 million. Horizon’s nine highest-paid executives fared even better, with a 61% increase in salary and bonuses from their 2008 compensation. The 2009 compensation for Horizons top 9 executives totaled 24.3 million dollars. The majority of this money was given in the form of bonuses.


I have several questions. Perhaps someone could answer them for me?

Question #1: Bonuses used to be given as a reward to employees exceeded the expectations of their employer. With last years’ massive lay-offs, skyrocketing premiums, and reduced service, what exactly was Horizon’s board of director’s expecting?

Question #2: Horizon is a not-for-profit organization. They posted a loss of around 1 million dollars last year. They could have broken even if they increased executive bonuses by only 50% . How can a not-for-profit company be allowed to do this?

Question #3: Why is this man smiling?




Oh wait! I know the answer to that one!


***** Found this Interesting, Entertaining or Informative? Please read the complete blog at: *****
http://healthcarehullabalo.blogspot.com/


Free Blog Counter

Socialized Medicine

…the devil's best trick is to persuade you that he doesn't exist!"
"Le Joueur généreux," pub. February 7, 1864

Socialized Medicine. No two words strike greater fear in the hearts of Americans than socialized medicine. Once we are forced to endure socialized medicine, all hope will be lost. In the great health care debate, the phtase ‘socialized medicine’ is the nuclear warhead – dropped when desperate times call for a game-ending action. No one wants socialized medicine. Discussion over.

Socialized medicine means many things to the American people, but most importantly, it means the end of choice. Freedom and Liberty are the cornerstones of the foundation that this country was built upon. Losing ones Freedom of choice is the perhaps the greatest affront to our national character,
And that is why we will fight socialized medicine with our dying breath. For Americans, nothing is worse.

All I can say to my fellow, Liberty-Loving Americans is “WAKE UP!” In case you haven’t noticed, socialized medicine (or at least its consequences) is here. It has lived here, warm, fat and healthy, for many years. Remember this the next time that your doctor gives you a prescription.

When it comes to our prescription medicines, we really have no Freedom of Choice – we can only buy the specific brand of medicine that out doctor gives us the permission to buy. Yet, most of us remain oblivious to this fact. Do you have High Blood Pressure? You get a prescription for an ACE inhibitor. You can take benazepril, captopril, enalapril,fosinopril, lisinopril, moexipril, perindopril, quinapril, ramipril, or trandolapril. For most of these examples, you can take one of several name-brand drugs, or you can take its generic equivalent. There are of-so-many ‘prils to choose from – but not for us Americans. We can only buy the SPECIFIC ‘pril that our doctor gives us permission to buy. Yes, there are different side effects and interactions to these varied ACE inhibitors, but none of these drugs are particularly different or dangerous. Yet, when you go to the pharmacy, you are limited to the SPECIFIC ‘pril that your doctor gave you on the prescription. Your doctor gave you a prescription for quinapril, but lisinopril is on sale? - tough luck – you have to buy quinapril. You have a prescription for Zestril but it costs 5 times as much as generic lisinopril – you can’t buy the generic version without your doctor’s permission, even though it is the same thing. Your doctor most likely decided what ‘pril to prescribe based upon what drug rep last bought his staff lunch or dropped off a case of free samples, or took his family out to a ballgame or fancy restaurant. Or perhaps your doctor was swayed by some shady research report that shows that their brand of ACE inhibitor was marginally better in one way or the other. In any event, the choice of ACE inhibitor is not up to you, the consumer. This effectively eliminates competition between competing drugs at the consumer level. Completion at the consumer level is what drives prices down and keeps quality and innovation up. This is why over-the counter medicines cost a mere fraction of their prescription-only cousins..

This argument is not limited to ACE inhibitors. Similar arguments could be made for many other classes of drugs, from proton-pump inhibitor stomach medicines (Omeprazole, Lansoprazole, Dexlansoprazole, Esomeprazole, Pantoprazole and Rabeprazole) to cholesterol-lowering statins (Atorvastatin, Fluvastatin, Lovastatin, Pravastatin, Rosuvastatin and Simvastatin).

Why do we not have a choice? Well, the primary reason is that by taking the choice out of the hand of the consumer the prices can be driven up to the current stratospheric levels and even beyond. The argument is that the consumer does not have the intelligence, experience or knowledge to make the correct decision. However, I would counter that argument by saying that, thanks to the internet, many patients are more informed and knowledgeable than physicians were just a generation before. Patients who are not knowledgeable would always have the option to defer to their physician- or pharmacist – as to what drug would be the right one for them and their budget.

I don’t think that this could be done for all types of prescription drugs, but it certainly could be done for a large percentage of them. If physicians were only able to prescribe only a certain CLASS of drug (and still RECOMMEND whatever brand they wished), it would return decision making back to the consumer level, and start driving down the cost of many prescriptions. The Freedom of Choice as to what ‘pril, ‘zole or ‘statin to purchase would ultimately be in the hands of the consumer, and out of the hands of our pharmaceutical ‘Big Brothers’. This is right for so many reasons, but mostly because it is the American Way.

Until we see this change in the way that prescription medicines are prescribed, competition on the consumer level will be almost non-existent, and the prices of prescription drugs will continue to skyrocket. And well all know what eventually happens to a skyrocket…




***** Found this Interesting, Entertaining or Informative? Please read the complete blog at: *****
http://healthcarehullabalo.blogspot.com/

Free Blog Counter