I like your plan, it is simple, no new bureaucracy required to run it and we can help these patients, the earlier the better.

I would sign up for it.

Karola F. White, M.D.

It all summons up that the way to save money in medical care is to hold patients responsible for their health, instead of taking health for granted. Patients that have an interest in their health seem to listen better, follow instructions and come to appointments to prevent problems instead of waiting until there is a crisis. Life insurances have different rates for smokers and non-smokers, high risk takers and low risk people and give benefits for healthy lifestyles. If insurance companies would reward non-smokers, healthy lifestyles and people who get regular checkups it would save money. In psychiatry specifically, having the ability to go and see a psychiatrist prevents suicide, alcohol and drug abuse and chronic health and mental problems due to psychiatric illness of any kind. Blue Cross Blue Shield does not even allow psychiatric care any more and I have to specify that the medication “Zoloft” (a very effective antidepressant and anxiety medication) is used for “other than psychiatric” reason for my patient to have it reimbursed to him from BCBS (I don’t know the branch, specific policy or particular state this patient has it through). Tricare will not allow brand name medication “unless” the patient has had “severe”, meaning “hospitalization required” side effects to the generic, and even then they requested a retrial on generic Lamictal, after the patient ended up in ICU with Stevens Johnson Syndrome. The cost associated with ICU stay to “prove” that the patient can’t tolerate this medication is huge. The 8 year old girl with ADHD, doing well on generic Focalin, having to be exposed to a different medication with all the risks involved, because the generic Focalin is not available in the US (due to pharmaceutical not making it) and the Insurance refusing to give her the brand name to save money. These are all wastes of money and risks to patients that are simply not needed. Many patients who have to be exposed to numerous “preferred” medications, before they will be allowed to get what works with least risk and no side effects, due to the insurance companies dictating what the patient has to take, unless I take the time for the inevitable 45-80 minute phone call to the insurance company to explain why this is my medical decision, with most of the time is rewarded with the patient getting the medication I deem most effective with the least risk to the patient. But taking 80 minutes out of my day, cost the patients and me, not the insurance companies, who only stand to save money, because physicians can’t afford to do this. Nothing I can do about it, I tried.
Other factors contributing to the high cost of health care as I see it.
0. Showing up for appointments is not mandatory and too many patients see it as not needed and then call in crisis, need to go to ER with preventable events, if they simply followed up as scheduled. Aside the fact that it does cost me money, because of not getting paid if the patient is not showing up, and I am not allowed by the insurance company to bill the patient. The cost for ER visits, hospitalizations, needing to restart medications that have run out needlessly are staggering.
1. College and Medical School are very expensive, starting to make money in your 30′s with $ 100 K to 200 K in debt that needs to be paid off increases the amount of money a physician has to make to be able to afford a family.
2. While I worked in-patient child and adolescent psychiatry I saw many times that kids were admitted for ONE day and the insurance companies told me (the very next day) that the kid did “not meet” their criteria for being in the hospital and the phrase of “well doctor, we are not telling you to discharge the kid, we just won’t pay for it”, became routine, which is a reason why I quit. Also that insurance companies told me personally that unless I “medicate more aggressively” they would not pay for the stay and that insurance companies demanded daily face to face telephone contacts with their own doctors (of any specialty) to justify why they should continue to pay for the stay. Uninsured patients were seen for free by the MD, except that I am carrying the full responsibility for them for at least 21 years concerning malpractice. Finding out that the government reimburses the hospitals for uninsured patients seen and cared for, which never was passed down or shared with any of the MD’s as far as I know.
Only one insurance company allows RTC (Residential Treatment Center) stay, which in more than one case has helped so much, that no further hospitalizations or ER visits were needed and the kids and their families are thriving. The on call required to work in the hospital was excessive and totally unpaid, while the hospital profits from the ER visits with high charges and the physician having to be available for between 48 hrs and 7 days non-stop, ignoring the deleterious effect this has on patient care. During my time in the hospital three kids, ages 9-15 ended completing suicide, because after discharge they were not able to continue being seen by a psychiatrist, because of the lousy reimbursements, they could not find a provider, or because the family fell through the cracks. A simple follow up would have saved all three lives.
In my city of 2 million, Medicaid patients will not find psychiatric care as required, because these patients have the highest no-show rates and the reimbursements are too low to afford carrying these patients. In addition Medicaid takes up to a year of clean claims being submitted, re-submitted and kept track off that I had to chose between hiring a full time staff to get Medicaid to pay or let go of the patients. I love many of them and regret having to let them go. The quarterly letters by Medicaid to safe money under the “let-us-help-you-care-for-your-patients- pretense accusing me of malpractice by prescribing whichever medication they are trying to safe money on did not help either. Especially since these accusations of inappropriate prescribing is based on pharmacy records only, and no request from me, to please enlighten me on a “contraindication in this patient” has ever been answered. EG the teenager, who Medicaid claimed had a cardiologic reason to not be on Adderall, neither the teen, nor his family, nor my records reflected any “cardiologic” anything. Or the schizophrenic teenager, who lives with the delusion of being pregnant, with Medicaid simply accusing me of prescribing antipsychotic to a pregnant teenager. With Medicaid demanding medication changes every three months, which can’t be cost effective, with the patients being exposed to more medications, more relapses, more impairment and more hospitalizations needed to stabilize them.
3. In private practice, the cost are increasing, because I need to have staff to keep up with the insurance companies (2) that I am still taking, and this is difficult, since clean claims constantly get refused, because of insurance internal problems, because of the amount of calling involved to follow up with the insurance company, because of the paperwork required to get authorizations, which lately have been refused, even though given less than a week ago, causing me to have to pay overtime to my staff, which is not reimbursed. The reimbursements are not keeping up with increased cost of running the business, not even to break even from one year to another. I am more and more struggling and having to see more patients to make the same money as last year. I can’t afford the electronic billing and record keeping demanded by the government, however much I agree with the benefits they can provide. I looked into it, but the cost is undo able for a one MD place with no corporate financial cushion.

At this time giving my patient the health care they deserve and that I see working well with minimal hospitalizations needed and patients getting better with least amount of medications is costing me:

12 hour work days, 6 days a week,
24/7/365 having to be available for call/emergencies (all call care is not reimbursed by insurances and can’t be charged to the patient per insurance demands, but serve to keep patients well and out of the hospital, which saves the insurance money. It also saves money to keep patients on smallest amount of medications and teaching them the life skills that they need to keep themselves healthy, which is also not reimbursed by insurances. This is also not reimbursed, because you can only charge one event per day or two per week and the sicker a patient is, the more often they need to be seen to prevent bad things from happening.
Missing out on life.

It all summons up that the way to save money in medical care is to hold patients responsible for their health, instead of taking health for granted. Patients that have an interest in their health seem to listen better, follow instructions and come to appointments to prevent problems instead of waiting until there is a crisis. Life insurances have different rates for smokers and non-smokers, high risk takers and low risk people and give benefits for healthy lifestyles. If insurance companies would reward non-smokers, healthy lifestyles and people who get regular checkups it would save money. In psychiatry specifically, having the ability to go and see a psychiatrist prevents suicide, alcohol and drug abuse and chronic health and mental problems due to psychiatric illness of any kind. Blue Cross Blue Shield does not even allow psychiatric care any more and I have to specify that the medication “Zoloft” (a very effective antidepressant and anxiety medication) is used for “other than psychiatric” reason for my patient to have it reimbursed to him from BCBS (I don’t know the branch, specific policy or particular state this patient has it through). Tricare will not allow brand name medication “unless” the patient has had “severe”, meaning “hospitalization required” side effects to the generic, and even then they requested a retrial on generic Lamictal, after the patient ended up in ICU with Stevens Johnson Syndrome. The cost associated with ICU stay to “prove” that the patient can’t tolerate this medication is huge. The 8 year old girl with ADHD, doing well on generic Focalin, having to be exposed to a different medication with all the risks involved, because the generic Focalin is not available in the US (due to pharmaceutical not making it) and the Insurance refusing to give her the brand name to save money. These are all wastes of money and risks to patients that are simply not needed. Many patients who have to be exposed to numerous “preferred” medications, before they will be allowed to get what works with least risk and no side effects, due to the insurance companies dictating what the patient has to take, unless I take the time for the inevitable 45-80 minute phone call to the insurance company to explain why this is my medical decision, with most of the time is rewarded with the patient getting the medication I deem most effective with the least risk to the patient. But taking 80 minutes out of my day, cost the patients and me, not the insurance companies, who only stand to save money, because physicians can’t afford to do this. Nothing I can do about it, I tried.
Other factors contributing to the high cost of health care as I see it.
0. Showing up for appointments is not mandatory and too many patients see it as not needed and then call in crisis, need to go to ER with preventable events, if they simply followed up as scheduled. Aside the fact that it does cost me money, because of not getting paid if the patient is not showing up, and I am not allowed by the insurance company to bill the patient. The cost for ER visits, hospitalizations, needing to restart medications that have run out needlessly are staggering.
1. College and Medical School are very expensive, starting to make money in your 30′s with $ 100 K to 200 K in debt that needs to be paid off increases the amount of money a physician has to make to be able to afford a family.
2. While I worked in-patient child and adolescent psychiatry I saw many times that kids were admitted for ONE day and the insurance companies told me (the very next day) that the kid did “not meet” their criteria for being in the hospital and the phrase of “well doctor, we are not telling you to discharge the kid, we just won’t pay for it”, became routine, which is a reason why I quit. Also that insurance companies told me personally that unless I “medicate more aggressively” they would not pay for the stay and that insurance companies demanded daily face to face telephone contacts with their own doctors (of any specialty) to justify why they should continue to pay for the stay. Uninsured patients were seen for free by the MD, except that I am carrying the full responsibility for them for at least 21 years concerning malpractice. Finding out that the government reimburses the hospitals for uninsured patients seen and cared for, which never was passed down or shared with any of the MD’s as far as I know.
Only one insurance company allows RTC (Residential Treatment Center) stay, which in more than one case has helped so much, that no further hospitalizations or ER visits were needed and the kids and their families are thriving. The on call required to work in the hospital was excessive and totally unpaid, while the hospital profits from the ER visits with high charges and the physician having to be available for between 48 hrs and 7 days non-stop, ignoring the deleterious effect this has on patient care. During my time in the hospital three kids, ages 9-15 ended completing suicide, because after discharge they were not able to continue being seen by a psychiatrist, because of the lousy reimbursements, they could not find a provider, or because the family fell through the cracks. A simple follow up would have saved all three lives.
In my city of 2 million, Medicaid patients will not find psychiatric care as required, because these patients have the highest no-show rates and the reimbursements are too low to afford carrying these patients. In addition Medicaid takes up to a year of clean claims being submitted, re-submitted and kept track off that I had to chose between hiring a full time staff to get Medicaid to pay or let go of the patients. I love many of them and regret having to let them go. The quarterly letters by Medicaid to safe money under the “let-us-help-you-care-for-your-patients- pretense accusing me of malpractice by prescribing whichever medication they are trying to safe money on did not help either. Especially since these accusations of inappropriate prescribing is based on pharmacy records only, and no request from me, to please enlighten me on a “contraindication in this patient” has ever been answered. EG the teenager, who Medicaid claimed had a cardiologic reason to not be on Adderall, neither the teen, nor his family, nor my records reflected any “cardiologic” anything. Or the schizophrenic teenager, who lives with the delusion of being pregnant, with Medicaid simply accusing me of prescribing antipsychotic to a pregnant teenager. With Medicaid demanding medication changes every three months, which can’t be cost effective, with the patients being exposed to more medications, more relapses, more impairment and more hospitalizations needed to stabilize them.
3. In private practice, the cost are increasing, because I need to have staff to keep up with the insurance companies (2) that I am still taking, and this is difficult, since clean claims constantly get refused, because of insurance internal problems, because of the amount of calling involved to follow up with the insurance company, because of the paperwork required to get authorizations, which lately have been refused, even though given less than a week ago, causing me to have to pay overtime to my staff, which is not reimbursed. The reimbursements are not keeping up with increased cost of running the business, not even to break even from one year to another. I am more and more struggling and having to see more patients to make the same money as last year. I can’t afford the electronic billing and record keeping demanded by the government, however much I agree with the benefits they can provide. I looked into it, but the cost is undo able for a one MD place with no corporate financial cushion.

At this time giving my patient the health care they deserve and that I see working well with minimal hospitalizations needed and patients getting better with least amount of medications is costing me:

12 hour work days, 6 days a week,
24/7/365 having to be available for call/emergencies (all call care is not reimbursed by insurances and can’t be charged to the patient per insurance demands, but serve to keep patients well and out of the hospital, which saves the insurance money. It also saves money to keep patients on smallest amount of medications and teaching them the life skills that they need to keep themselves healthy, which is also not reimbursed by insurances. This is also not reimbursed, because you can only charge one event per day or two per week and the sicker a patient is, the more often they need to be seen to prevent bad things from happening.
Missing out on life.