Guess how much this visit is reimbursed, in this scenario of newly-diagnosed breast cancer:
That’s where my office gets involved. Five or ten faxed pages arrive on my assistant’s desk. She calls the Gynecologist’s office to request additional material, including copies of the mammogram report, the patient’s contact information and insurance data-if the patient is insured.As it happens, like more than 60% of the women I care for, this patient is either uninsured or underinsured by Medi-Cal or BCEDP, the State of California’s breast cancer detection program for low-income women.
The paperwork piles up. Now my assistant must confirm eligibility in addition to scheduling the consultation, creating a chart and retrieving x-rays for me to evaluate. Prior to the visit, I review the chart and create an electronic medical record.
Next, the visit. Your neighbor arrives at my office. I speak with her for about 15 minutes, learning her medical and surgical history, asking about symptoms and risk factors, and answering questions.
I examine her carefully, assessing not only for breast abnormalities, but also for swollen glands in eight regions of the body. A heart and lung exam is done to identify problems that would make her a higher surgical risk, and the neurological, abdominal and musculoskeletal evaluations provide evidence for or against tumor spread.
After my patient is dressed, she asks me to bring her sister and husband in for the discussion of my recommendations. This is often the most time-consuming part of the visit, requiring patience, repetition and reassurance for a frightened patient and her concerned family.
Although our first visit has ended, the work has not. I fill out a form ordering testing to further characterize the abnormality seen on my patient’s mammogram. I’ll pore over a list of codes required by Medi-Cal to identify the visit, choosing the most appropriate ones and hoping they don’t merit automatic rejection of the bill (a frequent occurrence, prompting up to nine months of back-and-forth debate with Medi-Cal). Because the necessary biopsy requires a Radiologist’s assistance, I’ll communicate with him as well as the Pathologist who examines the specimen provided.
All that, for a bargain-basement reimbursement of $59.50.
Related posts:
- "The great majority of women in the United States should not be getting MRI scans for breast cancer screening"
- Does a breast MRI have any benefit for patients with breast cancer?
- The assessment of individual risk: Why the ACP recommendations won’t change a thing
- Being a woman vs being a doctor
- Risks of cardiac CT scanning
- Appeasing social conservatives: "It’s losing politics"
- Importance of a second opinion
{ 15 comments }
“patient is either uninsured or underinsured by Medi-Cal or BCEDP, the State of California’s breast cancer detection program for low-income women…”
You have to wonder how many hours of labor that is for a low income woman?
My feeling is that much of these ‘regular’ type of tests will be replaced in the near future by technologies. This is already happening in cosmetic medicine.
The marketplace forces that are causing a decline in physician incomes will necessitate a move away from individual physician labor and move to technology solutions.
During the transiton that will take place over the next 15 years, it’s going to be messy. Many physicians will not survive the change.
Physicians are terrified of what’s happening and rightly so. It’s only going to get worse. I receive inquiries every week from physicians who are looking to shed their regular medical practices and move to cosmetic medicine which they see as a solution. For some it is. For others it’s not.
Sorry for the ramble.
Is it any wonder why Medicaid patients have difficulty finding doctors? The story isn’t much different elsewhere. In many states, the schedules are just as low. Many states subcontract to bottom-of-the barrel managed care companies for their Medicaid pool, which treat providers particularly badly, delaying payments, denying payments, finding ever more inventive ways to call dirty a manifestly clean claim.
Morbidly obese woman comes to the ER gasping for breath proudly displaying her Medicaid card. She has neglected to take care of her trach which she now has inhaled and is sitting near the carina, therefore she can’t be directly intubated. I literally spend an entire shift trying to care for her and get specialists to help out. After a billion phone calls and dead ends I finally end up arranging a Blackhawk helicopter (usual ones can’t transport her obesity) to take her to a tertiary care center.
Medicaid will probably pay me about 59$ (minus 8$ billing cost minus 15$ malpractice costs minus
8$ misc overhead costs = 28$) for spending 8 hours trying to save this ladies life.
Did you ever think about the flip side?
Medicare and Medicaid are funded with public dollars. Better reimbursement for you guys (which I actually do think you deserve) would mean higher program costs – and guess where the money comes from? Yep, from the taxpayers.
Why should I be taxed more so you can be reimbursed more? (Rhetorically speaking)
Why should *you* be taxed more so you can be reimbursed more and pay higher income taxes?
It’s all a shell game.
Brilliant comment – as shell game it is and we are the molluscs.
While these scenarios support your thesis, you might also bear in mind that not every physician visit is nearly this intensive. I’ve been to referred to specialists and spent barely five minutes with them — and still received a bill near $100. I have NEVER had the opportunity to discuss treatment with a doctor, even when I volunteered to pay for his time. Always, always get delegated to a lower-paid nurse.
The breast surgeon makes his money on the surgery, not on the pre-op visit. We have a similar situation in sleep medicine. Sleep physicians are underpaid for evaluating and counseling patients, and overpaid for interpreting sleep studies. It all works out in the end for the physician.
Dr. Rack,
It might work out for you and the surgeon, but not for the rest of us primary care schlubs.
“The breast surgeon makes his money on the surgery, not on the pre-op visit.”
Not exactly, Dr Rack. 80% of consults for breast problems do not involve cancer, so there is no surgery to “make money on” for the vast majority. For the ones that do involve surgery, we might be reimbursed $1000 or so if we are fortunate enough to have an insured patient. That $1000 sounds like a lot, expecially for what most surgeons can do in 1-2 hours. That $1000 covers not only the surgery, but 30 minutes or so of immediate post-op work (dictating the op note, writing orders, talking to the family, then talking to the rest of the family who were out smoking when the first conversation was taking place. The patient will be in the hospital overnight typically, and will require standard discharge work (what you would bill as a 99238) the next day. May well require home health care, involving a discussion with Discharge Planner, and forms to fill out. Then the post op care- several visits for wound check, remove sutures and drains, phone calls from patient, family, home health nurses. Fortunately complications such as hematomas and infections are rare, but when they do occur they require multiple visits in additon (you would bill 9921x for these visits; we get 0). Phone calls and arranging consultations with oncologists, radiation therapists, and Reach to Recovery counsellors are needed typically. All this for 90 days, included in the global fee ($1000 if we get it).
It is very rewarding to help a terrified woman get through this ordeal and be able to tell her that she has a very good chance of living a long and healthy life once her treatment is completed. If she has a poor prognosis, it’s much less enjoyable, but still rewarding to help her get through a terrible situation in the best possible way under unfortunate circumstances. But, no, the rewards are not financial. Your implication that caring for breast cancer patients is easy money is offensive.
“It might work out for you and the surgeon, but not for the rest of us primary care schlubs.”
I agree with that 100%.
JB: $1000 for breast surgery, including post-operative care, seems like a reasonable amount to me. But I guess only you can decide if it’s enough reimbursement for you to keep on providing your services. I never said that caring for breast cancer patients was easy.
“80% of consults for breast problems do not involve cancer, so there is no surgery to “make money on”. Isn’t there usually a biopsy involved?
The majority of breast cancer diagnoses are made from needle biopsies, some done by radiologists, and some by surgeons. The open biopsies are reimbursed at a much lower rate, but with analagous perioperative policies, including the 90 day global payment policy.
You did not say that caring for breast cancer patients was easy, and I did not allege that. I objected to your characterization of breast cancer care as being similar to your sleep study interpretation, which you described as “overpaid.” I will accept your description of your own work as overpaid. I earn every dollar that I get from my efforts. Considering the time and effort required, inherent responsibility, and difficulty of my professional efforts, I consider my reimbursement to range from zero to barely adequate. Maybe I could do a few sleep study interpretations on the side. I hear that they pay real well.
maybe he should be known as Micheal Racket md.
So if you’re all losing money on every procedure, how come you are compensated at a higher average rate than any other profession in the world? Is the Dept. of Labor wrong?
because we work harder than any other profession in the world
“So if you’re all losing money on every procedure, how come you are compensated at a higher average rate than any other profession in the world? Is the Dept. of Labor wrong?”
That is a fatuous and stupid comment. Dishonest, too.
You would lose money if all your patients had Medicaid. If you are lucky, only a small and predictable percentage of patients will have that coveage. But for all those whose coverage undercompensates for their care, there have to be two or three or more whose net payment leaves enough surplus to cover the loss. That is simple enough to understand.
But you weren’t so interested in understanding, you just wanted to drop off that deliberately misleading labor statistic, as if it were some kind of refutation, which of course it isn’t. That labor statistic doesn’t consider the much greater investment cost and opportunity cost to becoming a physician. It doesn’t count consequent reduced career length, or the absence of pension benefits and other typical non-pay personal benefits like paid vacation that other workers get, but which don’t show up on average gross income figures for an entire class of workers. Why not average all baseball players, or musicians.
So why not consider income per career years worked discounted by investment cost, normalized to a typical basket of employee benefits? Well, that might require some work, wouldn’t it? Far easier to dish out the lazy lie.
Comments on this entry are closed.