Transparency is here, and it’s hunting season on doctors

It’s here. For the first time in 35 years (or 33, depending on which click bait headline you clicked on), the much anticipated release of data on Medicare payments to physicians, has been released to the public, on the historic date of April 9th, 2014.

“Data trove shows U.S. doctors reap millions from Medicare,” according to the distinguished Reuters news service. The Washington Post will tell you “everything you need to know about today’s unprecedented Medicare pricing data dump” and Pro Publica, which specializes in rendering doctors transparent, is announcing more tools for picking doctors coming soon, based on these data. If you want to read juicy stories about a handful of crooks who happen to have a medical license, and who were already under investigation by Medicare, click on some of the links above or below. If you want to understand what this all means to you, stay with me and keep reading.

The data released by Medicare includes the doctor’s name, address and specialty. For each physician, there is a list of CPTs performed for more than 10 patients during CY 2012, and for each CPT there is the number of unique patients billed for the procedure, the number of times the procedure was performed (or billed to Medicare), the average charge per CPT and the average payment for the same. There are over 800,000 names on the list (not just physicians), so chances are good that unless you are a pediatrician or a concierge doc, your name is on it. Of course, this is just the preliminary raw list, but given enough time and innovative efforts, many, many sub-lists will be evolving. Even before the list was released to the public, several publications with advanced media access, managed to quickly produce high-spender lists, so stay tuned to your favorite news outlet for more to come. Until then, the New York Times has the best search tool, so go ahead, look yourself up. It’s okay; everybody else is doing it.

One thing to note is that the data does not include Medicare Advantage patients, so right off the bat almost a third of Medicare patients are excluded from this data trove, not to mention the exclusion of Medicare Advantage bonuses from our newfound transparency. So if you find a geriatrician that reaped only $2,056 from Medicare, try not to worry too much. Chances are the guy or gal is fully loaded with Medicare Advantage patients. Commercial payers are obviously not on the list, but neither is Medicaid. We all know that Medicare payments are just the tip of the iceberg and doctors get additional boatloads of money from private insurance, and if we don’t know, I’m sure we will be so advised by the media in the next few days. But in the interest of full transparency, wouldn’t it be enlightening to see Medicaid’s relative contribution to doctors’ wealth? I mean defrauding the elderly is pretty bad, but defrauding hungry children, should give the upcoming three-part expose pieces so much more oomph …

On the White House blog, Todd Park is telling us that “New Medicare Data Offers Unprecedented Transparency for Consumers.”  Considering that the Medicare physician fee schedule was always public and anyone could see the price of any service in any locale, and considering that the total amount Medicare is paying out to doctors is also a fairly well known number, what is it we didn’t know?

Lots of stuff. First, we didn’t have an itemized list of how much Medicare is paying each doctor for each individual service. Now that we do, we can learn, for example, that Dr. X in St. Louis has billed Medicare 200 times for venipuncture (at $3 apiece) for 100 patients and also billed for about 200 office visits for 100 patients. It seems that if you go see this doctor, you will invariably end up with a needle in your arm, so better find someone else who is not going to hurt you just because you showed up, and have all sorts of unnecessary tests done on you. See how helpful data can be to an informed consumer? Don’t worry; you won’t have to engage in such complex analysis for much longer, because journalists and unemployed technologists are busy building 4th grade literacy level tools and decision aids for all of us.

But that’s nothing compared to the power of implied impropriety. There are two dollar columns in this unprecedented trove of data, one is what the doctors billed Medicare and the other is what Medicare paid. A while back Medicare released a smaller unprecedented trove of similar data for hospitals with the same two columns. That too was hailed as a new era for informed consumers who will now have the ability to choose hospitals based on the value they provide. Fast forward to today, and all that remains from that particular trove are a bunch of articles highlighting the immoral variations between hospital charge master prices and their effects on the uninsured. Since physicians’ data exhibits the same discrepancy between what is billed and what is paid, and since nobody cares to understand why and how those charges end up on claims, you can expect similar stories about uninsured people being charged “sticker prices.”

On a side note though, how come people are uninsured? Isn’t it illegal to be uninsured? Shouldn’t you just head over to Healthcare.gov and get affordable insurance instead of complaining about prices for the uninsured?  Yes, you will end up with a high deductible, but you won’t have to pay sticker price, and I’m sure there will be some in-network facility within driving distance that can treat chest pain, and if there isn’t, maybe as an engaged patient, you should buy one of those iPhone defibrillators Dr. Eric Topol is using on airplanes, or was it an Android EKG, not sure. But I digress.

What else can we do, or are expected to do, with this data treasure? Well, it seems that CMS is asking all of us to grab a magnifying glass and play “Where’s Waldo?” with this unprecedented trove of clues for how Medicare is being defrauded by doctors. CMS, it seems, has no ability to systematically flag the chiropractor who bills upwards of 150 manipulations per patient per year, so it keeps paying and paying ad infinitum. In lieu of building a few cheap algorithms, why not throw the entire database out there and see if taxpayers can obtain some free fraud detection from the public at large? Sort of like the sheriff used to put together a citizen posse to chase and apprehend criminals in the old west … The criminals, particularly the ones not guilty of any crime, should adapt and learn how to use Big Data troves to defend themselves, with the added benefit of accelerating “trends toward large medical groups and doctors working as employees instead of in small practices,” per the Huffington Post. That is a good thing too, because dealing with organized crime is so much better for society than dealing with petty theft.

Where does this leave individual physicians? Well, you could run for the nearest rock and crawl under it until this too shall pass. Alternatively, you could start generating some educational content of your own, trying to explain to your patients what the troves of data mean, and what they don’t. You could put together more complete data, at least for your own patients, and address the clinical rationale for those completely out of context data points. You could write for larger audiences, and you could contact your local media offering to provide some balance to the tabloid stories about millionaires injecting people in the eyeballs with Lucentis.

The one thing I would recommend you don’t do, is to seize this opportunity to vent your frustrations with higher paid specialties, because the media is already doing that, and because this is exactly what they want you to do, and because in the eyes of the public there is no difference between this or that specialty. It’s hunting season for all doctors, and you will not save your neck, or your specialty, by joining in the hunt for other species.

And finally, considering that the median amount of money doctors were reaping from the program for the elderly and the disabled was around $30,000 per year, I can’t help but wonder if some business decisions are not highly overdue, for some people. Just sayin’ …

Margalit Gur-Arie is founder, BizMed. She blogs at On Healthcare Technology.

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  • DoubtfulGuest

    Educate your patients about overhead…that would go a long way I think. I particularly hate to see how cognitive specialists are caught in the middle. Few procedures, getting lumped in with the higher-paid specialists in public perception, all while we complain about doctors not taking time to think and listen.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      That’s a fantastic idea!!
      How would you feel about encountering little brochures in the waiting room, nothing overtly mercenary, and maybe even something funny, with cartoon-like appearance, showing where the “money” is going in a real practice?
      Should I spend some time making a tri-fold like that, customizable maybe with a place for practice name and such, and post it out there for primary care docs to download and use?

      • DoubtfulGuest

        I think that would be great, Margalit, and please do let me know if I can help somehow. I think quite a few people would find it eye-opening. It would be like “Oh yeah, they do have to keep the lights on. And that’s where the nurses’ pay comes from…”. There’s this veil of secrecy in medicine that makes it hard for people to imagine the day-to-day stuff. Some of it’s an attitude problem among the public, yes. But I think many people are looking for *real* transparency these days.

        Most importantly, we need to emphasize that the money goes everywhere else besides the doctor’s wallet, first. And for some unlucky docs, that means no paycheck at all for months at a time. One of those I’m thinking of is a cognitive specialist…please let’s include them as well because they’re in as bad a spot as many PCPs?

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          Let’s build it here… on this thread….Let’s make it a group effort….

          Folks, we need ideas… Instead of the customary complaining, let’s do something real!

          Where is the money going?
          How much?
          What is important to convey?
          How would you lay this out?
          Other?

          Don’t hold back… Every thought counts… There are no wrong ideas……

          • Patient Kit

            Include info about how much the doctor spends to provide health insurance for his staff (assuming the doc provides health insurance for staff). It would inform patients about where one big chunk of the doc’s income goes while simultaneously enhancing the doc’s image as a caring, compassionate person who cares about and takes good care of his staff.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            S3: Doc’s expenses on things perceived as caring and positive by patients, such as health insurance for staff.

          • Lisa

            You know, not all doctors provide health insurance for their staff. Some do, some don’t. Some doctor’s care about their staff, some don’t based on the behavior I have seen in doctor’s offices.

          • Patient Kit

            I agree. One of the docs here said all the doctors in his area do provide health insurance for their employees. But I know that I have talked to women who work in doctors’ offices who say they have no health insurance. I would love to see some numbers on how many private practice docs across the country do cover their employees. If most do, that’s good PR for docs. But if a significant number of people employed by doctors have no access to medical care — not good. I hate seeing anyone have no access to healthcare and it seems even more wrong when people work providing others medical care and have no access to it themselves. I wonder if there are any stats out there on this.

          • LeoHolmMD

            So many myths out there to dispel.
            I think patients would be interested/enlightened by MGMA data, like the value of the RVU and how these things are calculated. (Insert loathing of RUC here).
            Perhaps a “cost of bureaucracy” statement. Put it on the bill, like the utility companies, except call it “HHS tax”. Or maintenance of certification costs. You could include that on the bill under “extortion”.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            S4: Highlight insane complexity of how payments are decided by CMS
            S5: Highlight cost of complexity and lack of transparency

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          S6: Overhead (utilities, payroll, insurance, supplies, rent, professional fees….)

          What else?

          • DoubtfulGuest

            Some info about med school loans?

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Good catch…

            S7: Student loans for med school are larger than most

        • B Viner

          Do we really need to justify our income? Don’t people really just want to know what something (procedure, office visit, test) costs? Are we going to start examining our mechanics income or your hairdresser’s income and expenditures? I can’t see where this will make healthcare better. For the record, when I left 3 years ago my liability insurance as an Ob in KY was over $70k per year and Medicaid paid around $1900 for prenatal care and delivery. Overhead was climbing to near 60% and what’s left I got taxed on. You couldn’t trust your colleagues that you were in practice with when it came to money and every year we could count on some government entity to add more headaches. And it took 11 years to pay off my med school loans. It was $105k in principal and you would need a forensic accountant to figure the interest that was added in. Fix the student loan system while you’re at it.

          • DoubtfulGuest

            I see your points, Dr. Viner. The whole objective of this would be to counter some of the recent deceptive media releases about doctors’ incomes, which will arguably make life even harder for docs than it already is. I hadn’t even thought about it as “justifying the income”.

            People see so much bloat and waste in health care, and it seems like it could be helpful to show numbers so they understand the vast majority of that is not going to the doctors. In fact, many docs are struggling in this corrupt system. Folks want to know why things cost so much, and they tend to point the finger at docs. There’s no big gap between reality and public perception regarding hairdressers’ and mechanics’ incomes, that I’m aware of. This should be an optional thing, for docs to download and distribute, or not. Although we ought to take into account that making such data available could affect public expectations of docs who don’t want to participate…Margalit, which numbered “S” is this one? We’re only brainstorming today, Dr. Viner.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            S11: Should this contain “real” data or just general notions, averages and such?

          • B Viner

            I’m all for openness. Past articles have reported already that doctors incomes are <12% (from memory) of the entire expenses in healthcare. I just know that all this does is breed jealously and envy. I know I get that way when I hear how much some of my colleagues in other specialties get paid. But we docs need to come together to correct the system and inciting resentment is a possible outcome of sharing salaries.

          • DoubtfulGuest

            So, might a general, abbreviated brochure still be helpful, or no? As I understand it, the whole point is to take focus away from doctors’ salaries, and make it a closer look at everywhere ELSE the money goes. But when you get into student loans and stuff, I do see what you’re saying…

            Ah, another question, what about doctors’ CME, re-certifications and so on? In a group practice, are these paid for by the group, or does each doctor just take care of his/her own costs with these things, no matter what practice model s/he works in? I’m looking for patterns here, not trying to get too personal with anyone. Thanks.

          • B Viner

            My patients never discussed my pay with me. We tended to discuss their ailment. Any billing problems were usually with the hospital. If you are trying to sway the opinion of very opinionated people online then a pamphlet in your office won’t do much. In general, doctor’s make a good income, but it is decreasing. Whereas CEOs and sports stars are heading the other direction.

            Various ways of running a group practise. Some of the income is usually pooled and expenses are taken from that which would include CME costs with an annual limit of course. We had a $3K yearly amount. It’s still your money generated from the income of the practise, but any amount greater is paid for by your take home pay.

          • DoubtfulGuest

            Thank you. Duly noted. I wonder what effect articles such as the recent NYT “data” are having on how patients relate to their doctors in the office? Like are they making nasty comments? I don’t know. I was imagining a brochure might help with that sort of thing. It seems like at least a few docs want something like this. Some have said on this blog they are trying to explain to patients, and this would be an illustrative tool to help with that (and save them time, to get back to the patients’ ailments). I’d like to get a better sense of how many docs are interested, though.

          • B Viner

            I also was surprised by the NYT article and how much revenue some were receiving. Historically if the govt finds out you are making money, they will take care of it. Cataract surgery used to be more difficult and time consuming and when it became “easier” the eye surgeons were making the same fee and could do more cases as the procedure time became shorter. Well that gravy train was ended when the fee was reduced by the govt years ago. Don’t worry, there are plenty of entities at work making sure that doctors don’t make “too much”. We don’t even get free pens from drug companies any more. But it’s fine for our Congress people to be wined and dined by special interest groups.
            Personally, I am not a money oriented person by nature. I don’t look at patients charts to see if Medicaid or insured. All I ever wanted was to take care of people and earn enough to really not give it much thought. Unfortunately, it has morphed into a business model of care and for that, I am entirely unprepared and dissatisfied. Salary, to me, used to be just a fringe benefit of the life’s calling. Now it seems to be on everyone’s mind along with how best to manage this patient without getting sued for any unexpected outcome.

          • DoubtfulGuest

            I was perceived as a liability risk and summarily dumped by multiple docs when I really needed care. Despite all their screw-ups, I’ve never sued a one. Their risk assessment was way off. Just sayin’. I like your other comments, though.

          • B Viner

            It’s a shame because people suffer because docs are becoming gun shy when it comes to high risk patients. It’s bad for their “stats”. Maybe we docs should have baseball cards with all our info on them and our stats on the back. Like my patient survival rate is 0.350 or so, kinda like a batting average. BTW that 0.350 was not an actual medical stat. I just pulled it out from my 8th grade batting average.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Maybe you should have stuck with baseball… :-)

            Unfortunately, what they measure for physicians is not survival rate, but some other midpoint stuff that may or may not affect survival. It would be like counting average times you make contact with the ball… indicative, but hardly meaningful.

          • B Viner

            If you knew my 9th grade batting average, you’d know why I couldn’t stick with baseball;)
            That’s why I don’t think P4P will be good because outcomes are more that just physician dependent.

          • DoubtfulGuest

            Also, would something more general be appropriate? What range is there on overhead, student loan debt, and so on? I’ve read overhead is often 50-60%, student loan debt over 100k? Would you vote to scrap this idea altogether, or would you see benefit in something that helped people understand the components of where their money goes…without getting too specific?

          • Patient Kit

            You couldn’t trust your colleagues that you were in practice with when it came to money? I’m not sure exactly what that means but it sounds like a big problem.

            I’m all for the government subsidizing medical education in this country. It would take docs’ med school debt out of the equation of the cost of being a doctor and we could draw from a bigger pool of potential docs if med school wasn’t so prohibitively expensive.

          • B Viner

            Money is the root of all evil you know. When you have more senior docs that are accustomed to a certain level of income and then over time reimbursements shrink and overhead increases annually by double digits, the true human nature comes out.

            I did not find the tuition to be that bad, but the banks with the blessing of the federal govt can charge 8% compounding interest plus origination and guarantee fees and the fact that you don’t make a decent income until 8 years later = a sizeable amount of money.

            Here in NZ, a student loan is at 0%. Isn’t that about what the Fed charges banks to borrow money in the US? Wouldn’t you love to borrow money at near 0% and then loan that to someone at 8%? Our govt at work helping the powerful squeeze the powerless.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            That seems to have finally dawned on some Senators here. Not much chance that things will change, but I know Sen. Warren is talking about it in exactly the same terms you are.

          • B Viner

            They won’t do anything because they need the campaign donations from the banking industry. Our lobby can’t compete with all the others.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            People who are involved in health care for various reasons, know that overhead, debt, med mal, should be deducted from payment amounts. Very few though can accurately estimate the percentage. I can guarantee that the overwhelming majority of the public
            has no idea that the millions of dollars screaming from the headlines
            are not going straight into doctors’ pockets.
            So while I don’t think physicians should post their balance sheets in the waiting room :-), maybe a qualitatively informational little brochure to counteract the intentions of those who are literally feeding off the misconceptions, can’t hurt and may even help.

            Thinking about it this way, is there anything you would like to see in a PR piece like the one discussed here?

          • B Viner

            A private practise is a small business just like many non-medical businesses. The main difference is how we are paid. That’s the part that people struggle with. (Why what we bill is not actually what we get?) I can’t even explain why it is what it is. It made more sense to me when it was simple ol’ fee for service. I think the “transparency” needs to come from hospitals and insurers primarily. But then “transparency” is only what the powers that be want you to be able to see. It may or may not represent truth or reality.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Precisely. So let’s have a little transparency that does not originate from the darkest quarters, with the most questionable motives….

          • B Viner

            I’m fine with that. I could post my monthly checking account statement. My wife has to pay the bills because I find it too depressing.

          • doc99

            Don’t forget Maintenance of Certification.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            S13: MOC

      • NPPCP

        I would definitely use for my practice.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          Any ideas of what you would want to see on it?

          • NPPCP

            The important “big ticket” items that people don’t realize that I would like to convey (some of them) – always have an RN or LPN on duty. Big bucks there. Remind them “we are paid when we see you”. If we do something for you and don’t see you, we don’t get paid. Medical Supplies. “If you see it, I had to buy it.”. And, we have the same expenses as any other business – CPA, rent, liability, and multiple licensing fees. I halso have to pay a physician ALOT of money a month – just to use his name. Those are the big ones.

          • DoubtfulGuest

            “If we do something for you and don’t see you, we don’t get paid.”

            Also add no-shows to the list, unless you have a fee? Even then, it doesn’t fully cover the loss, does it?

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            S8: “If we do something for you and don’t see you, we don’t get paid.” Remember no-shows…

          • DoubtfulGuest

            Highlight the separation between the docs’ offices and labs/imaging facilities where they (frequently) exist? I’m not up to speed on what’s legal and what’s not, but I know people who believe their docs get money from ordering stuff even when they go off-site to a completely unrelated lab or imaging facility. Even when the patient chooses the facility, they sometimes think that.

          • B Viner

            Docs can own a portion of a medical related business, such as a surgery centre or lab, but by law the portion is limited to 5% or less I believe. Also we can’t steer you towards that particular business if there are other options. It’s been a few years since I looked at this, but should be fairly accurate.

  • Luis Collar, M.D.

    Great piece, Margalit. This will probably make me sound like an idiot, but even after an undergraduate degree and medical school and residency training and more than an adequate amount of years on this earth (lol), I find it difficult to logically explain some of the private insurance / medicare billed vs collected amounts on “statements” that my own parents receive. And these statements by the way (just tried to interpret another one last week for my dad), often have more than two columns of conflicting information. What ever happened to the principles of accounting?

    Statements from hospitals, insurance companies, and most healthcare data really, don’t mean much at all, at least not what they are intended to mean or would usually mean in other industries. The problem is that the business rules in healthcare that generate the data are so twisted, variable, and often nonsensical that the data itself is meaningless in many ways. That is, there is, in fact, meaning there, but it requires a great deal of knowledge, effort and, in some ways, luck to draw meaningful conclusions from said data. Just my two cents. But again, really enjoyed the piece.

    • Patient Kit

      Ah, those mysterious statements from health insurance companies. For all the years I was covered by Blue Cross and the three major surgeries I had during that time, many trees were killed to mail me reams of paper. I always assumed the amount paid was the contracted rate agreed upon in a contract between Blue Cross and doctors.

      But the extremely different amount of the fee submitted by the doctor was always a big mystery to me. If docs know that the contracted fee that BC will pay for a procedure is $500, why do they submit a bill to BC for $5,000? And why does BC want patients to have that info? And is that $5,000 the fee that doctor charges to the uninsured?

      On the other hand, in my new world, for the last year, when I’ve been covered by Medicaid, I get absolutely no statements about what Medicaid paid my doctor for my cancer surgery and no info about what fee the doctor submitted. It’s a whole different mystery.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        S2: Explain why charges are so much higher across the board and whether those are real for anybody.

        Question: is anybody here actually collecting charge amounts for cash only patients?

        • ninguem

          A typical practice is to peg the fee to the payment of the “better” insurances in your area.

          Fee is “reasonable” because insurance company says they will pay it.

          “Cash pay” patient is paying what insurance would have paid.

          It is reasonable to discount fee for payment at the time of service.Write a check for payment on the spot, or swipe a credit card, and the patient actually pays less than insurance payment.

          That discount is available to the insurance plan, if they were willing to wire that payment directly to the doctor’s practice bank account. In reality, that’s not going to happen.

          That’s private docs. The hospitals, the hospital-owned practices, they were notorious for huge fees for cash patients. I hear that happens less nowadays, but don’t know.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Yeah… what I’ve seen done is that folks take the “best” or highest multiplier for the Medicare fee for that one CPT and add some to it just to be safe and then multiply the entire Medicare fee schedule by that factor. Sometimes the numbers are close, sometimes they are way higher. The alternative is to tinker with each CPT manually and watch for any unannounced changes. It’s just not doable… and people don’t really understand that if you bill less than the current allowable you will be paid the lesser amount…. It’s such crazy stuff….

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Thanks, Dr. Collar. I am going to start numbering these things (S is for suggestion).

      S1: So we have the EOB – a simple explanation of charges vs contractuals/allowables vs patient responsibility, and why these are different numbers…. simple (and funny) being the keyword – and how by definition this makes things more expensive

  • ninguem

    If Medicare has the payment data, then Medicare has the BILLING data.

    Release what that doctor BILLED to Medicare, and compare with payment.

  • ninguem

    In my small town practice, we’d have similar problems with “transparency”.

    The hospital is part of the taxing district, there is tax paid to support the hospital, otherwise it would go out of business.

    The hospital hires certain consultant specialists. The area is so impoverished, that the hospital has to subsidize the orthopedic surgeons, or they would go bankrupt.

    Pretty bad when the orthos can’t make a living.

    OK fair enough, they wouldn’t starve, but they would realize they could make so much more in an urban area…..and I mean multiples of that they made in a rural area, double their income or more……that they would otherwise not even consider a rural practice.

    Thing is, the doc’s salary is often a line item in the hospital’s budget, and as such a public document.

    So the doc’s income becomes a public comment……in a small town.

    I’ve seen the dollar figure, it’s a good income, but average for the specialty, and the doc would likely do better in an urban area, without the constant on-call duty for a rural area.

    And remember,especially for a specialist. That doc has to be available to the hospital on very short notice. Thirty minutes or less, usually. Especially surgeons, obstetricians, anesthesia personnel. They’re taking call from home, the hospital is too small for in-house coverage apart from the emergency department (and that was started about 20 years go).

    …..before that, there was a nurse guarding the door to the ER, the nurse made the judgement call if you were sick enough to call the doctor out of the office or home to see you………

    Bear that in mind, when you thing of the rural area as a “hunting or fishing paradise”, hiking, nature, all the supposed attractions of rural life. That beautiful forest or lake outside your door might as well be the moon, if it takes you a long time to get off the rural dirt road back to town. You can look at it, but not enjoy it.

    You get the town……and the townies. The stereotype of the doctor and golfing.

    In some rural practices, the country club is the only place where you can get a good restaurant meal. Been there, done that, and I don’t even golf.

    Guess I joined to play “country”, not golf.

    So with all that, the doc’s salary, which is average but not great for the specialty, but admittedly a good income…….becomes the topic of gossip in the feed and grain, the hairdresser salon, the supermarket.

    With the jealousy and resentment. Especially if the local had a bad experience with the doctor, by being told to lose weight or stop smoking or whatever.

    Sometimes the issue comes up at a public forum, where the doc is put on the spot to justify making a living.

    And maybe the doc concludes rural practice is not worth it, and leaves for the relative anonymity of urban practice.

    Now the townies can drive 100 miles one-way to see that same specialist, when they realize they’ve driven their doc out of town.

    • NPPCP

      Wow – well said!!!

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      This exactly describes several places I’ve seen in rural areas in the
      South. I drove there from the city and I was a bit surprised (to put it
      mildly) to have a meeting scheduled at the “club” until I realized what
      was going on (long before I found the “club”)….

      S9: Rural medicine – maybe we need several versions of this brochure…

      • Dr. Drake Ramoray

        Welcome to my world. I use to have patients who refused to drive “downtown” the 30-40 minutes to the hospital. I sometimes had to treat dangerous hyperglycemia in the office with IV Fluids and insulin for half a day.

        Practice got bought up by corp med and I wasn’t productive enough and didn’t order enough tests and radiology studies. What radiology studies am I supposed to order for a patient panel that is 2/3 diabetes? I was the only Endo for almost two entire counties. Not always the populance that drives the docs away. Had to get out of there.

    • buzzkillerjsmith

      Oregon. Say no more. Not that’s there’s anything wrong with Oregon. Some of my best friends are Oregonians. Yeah right. But my family does live in Medford. I plan to go down there again should there be a funeral. Otherwise they have to come up here, which they never do since they’re, uh, Oregonians and crossing the Columbia River is nothing to do without good cause. So things work out pretty well.

      Orthos needing the hospital to survive?! Wow. Reminds me of the old Cheech and Chong bit about how times were so hard they saw a pimp driving a Volkswagen.

      I suspect you live either along I-5 or in a blighted coastal town. You don’t live in Bend or in eastern OR, which I actually don’t mind at all. Cowboys are easier to deal with than unemployed loggers. Plus the Wallowas. Very nice. We should annex that part of the state, but I digress….

      Please tell where you live so I can never work there or even drive through town. Just a general location will do. No need even to name the county.

      n, do yourself a big favor and move up one state. You’ll be glad you did.

      • ninguem

        Oregon is a land of many names.

        “California’s Canada”

        “Washington’s Mexico”

        I like Colbert’s take.

        “Idaho’s Portugal”.

        On that note, let me put in a plug for this Oregon winery.
        http://www.coelhowinery.com/

        • buzzkillerjsmith

          That was funny. I aspirated some of my beer.

    • Rob Burnside

      Throughout America, and perhaps throughout the world, there’s a small town ethos many fail to grasp–”when in Rome…” In choosing to remain apart, we suffer the consequences, however unfair and illogical they may seem. Townies don’t expect you to be exactly like them, but they’ll respect you, and even revere you, if you make the attempt. Joining the twilight golf league, no matter how limited your time or how badly you play, might have made all the difference. Fore!

      • ninguem

        Is there a fly in the room?

        • DoubtfulGuest

          I asked him to come over and join the thread, Dr. ninguem. :)

          • ninguem

            I’ve practiced in several small towns.

            One, my partner carried a gun to and from the hospital. Coming home at night, he’s had to pull it on local yahoos that threatened him.

            I understand, I’ve had to drive to the State Police station under similar circumstances. I probably would have got firearms training and a carry permit if I’d stayed there. A doc in town got shot by an idiot hunter walking his dog in the woods near his house. No one should have been hunting anywhere near there. Rapists were working the hospital parking lot and getting the nurses. They kept an armed guard in the lot at change of shift. The doc that replaced me when I left, a local boy coming back home, his fiancee got jumped in that same parking lot, she fought back and the clown ran off. The local boy quickly found a practice elsewhere. The rapists were killed in a shootout with police.

            I left there, for an academic practice in Chicago. I felt safer in South Chicago than I did in that rural practice. Not even close.

            The well-to-do of the rural area, perceived the nearby mid-sized city was where The Good Doctors practiced, they went there for routine care, saw me when inconvenient to go to nearby city (read – nights and weekends). Nearby mid-sized city was population 40,000.

            So……day filled with Medicaid, trauma, Medicare. Bread-and-butter work went to nearby town. I was making crap for money. I mean it, I was not only safer in Chicago, I was economically better off.

            I went back there to visit, five years later. There is not one single doctor that I knew from five years ago. They all left. Every single one.

            Check out Ann Alpers article from the Journal of Law, Medicine and Ethics, about fifteen years ago.

            http://www.hospicepatients.org/palliative-prosecutions.html

            This was an article on doctors that provided good-faith pain treatment to dying patients, and got charged with murder for their efforts. The cases were gross miscarriages of justice. Care provided was perfectly acceptable, maybe professionally quibble on details, but not even civil malpractice, let alone murder.

            I quote:

            “The most notable element of these cases is geography: they tend to be rural. With the exception of the Hennepin County and the San Francisco and Beverly Hills investigations, none of which proceeded to indictments or formal charges, all of the cases occurred in small towns or rural counties. Many of the health care providers were outsiders–either newly arrived,members of racial or ethnic minorities, or living alternative lifestyles. Given that criminal processes can reflect majoritarian power, this last observation may reflect troubling patterns of prejudice or injustice.”

          • Rob Burnside

            Sounds like a fairly nasty town, Doc. Perhaps you should have been more selective. I judge them by the plumpness of the squirrels on public square and the availability of rest rooms at the convenience store. (You know they have one but will they actually let you use it?).

            In all seriousness, I’d hoped to make a larger point.
            Somehow, over the last half-century, health care has become a stranger where it once thrived–in small town America. And the towns, for all their foibles, haven’t changed that much. So where does the fault lie? What, if anything, can be done about it?

          • DoubtfulGuest

            RB, I was just talking with a friend the other day about nastiness in small towns…was that you? I can’t recall, but whoever it was, we did agree that it can happen anywhere, like the mid-size city where I grew up. My particular brand of horse fly is from Switzerland, and I think the answers to your questions are pretty complicated.

            But sometimes people try to tell us stuff, like about their personal safety being threatened several times, or about being subjected to endemic racism, but they start off gradual-like. :) When we lived in a small town, my ex was constantly being pulled over by cops, “just to make sure everything is alright”. I have not lived enough different places to make generalizations, but I have also felt very safe in Chicago and less safe…elsewhere. Enlightening stuff…might we all pull together and give Margalit some help? We don’t have to agree on everything, but we sure can learn a lot here…

          • Rob Burnside

            Yes, DG, it was me, and we’ve both had our share of small town problems. I expect to be drawn and quartered any day now. Thanks for the invite and your suggestion– Margalit’s brochure–bravo! You’re right, we’ll learn. PS-Nice horse fly! (thought it was Drosphelia Melongaster for a moment)

          • DoubtfulGuest

            Sent you an e-mail, please do keep me posted and I hope you’ll stay with us in one piece. :) We’re trying to keep the brainstorming going at least until tomorrow, to see if the docs are ready to make something happen and if this is the right way to start.

          • Rob Burnside

            Good luck with this most worthy quest, DG. Unfortunately, as the first Don Diego said in the original “Zorro” movie–”I must seek repose.”

          • ninguem

            Yes, perhaps I should have been more selective.

            You’re right, it really was all my fault. Failure to do as the Romans do, failure to fit in, and finally failure to be more selective.

            The town described,by the way, was in Pennsylvania.

          • Rob Burnside

            Doesn’t surprise me, Ninguem. There are some areas of Pennsylvania that have endured so much misery they’ll be socially toxic for everyone–natives and newcomers alike–for generations to come. But, I can show you some lovely (and not necessarily “high-priced”) towns that would welcome you with open arms, instantly and forever. A lot of it has to do with recent (1.5 centuries or so) history–one of your many strengths. I make no excuses for my fellow Pennsylvanians. My family owned a department store. I went to private school. I had very poor comprehension of my neighbors’ plight, and all that went on around me, then and now. I can only excuse myself, and not very easily at that.

          • ninguem

            In the Venezuelan Crisis of 1902, we almost got World War One a decade early.

            Germany was looking for an excuse to defy the Monroe Doctrine and seize territory in The Americas. Venezuela’s inability to pay debt to Germany was an excuse as good as any.

            England did not care to see……what could have turned into World War One……..and was looking for someone to broker the deal.

            Roosevelt had just finished negotiating an end to the Anthracite Coal Strike.

            The Lords at Whitehall felt……seriously……that if Theodore Roosevelt could handle Schuylkill County, he could handle the Kaiser.

            He was given the task, and quietly settled the matter.

            If only the Bull Moose had been elected in 1912. Who knows, he pulled it off in 1902, again in 1905, maybe he could have made it a hat trick in 1914.

            It would have been a very different century.

          • Rob Burnside

            Indeed. No World War One might have meant no Treaty of Versailles, no Adolph Hitler, and no World War Two. TR is still revered here, along with John Mitchell. The settlement gave miners a true living wage–their first ever–and a humane workweek. You’ve framed it nicely, and I’ve learned a thing or two. And I must say I’m doubly impressed by anyone “from away” who can correctly spell “Schuylkill” let alone elaborate on the role this beautiful, but thoroughly traumatized county played in recent American (and world, as you’ve informed us) history. Where else would a best-selling novelist feel obliged to leave town? Thanks, on all counts, Ninguem.

          • ninguem

            Here’s how Roosevelt did it.

            From the Naval War College Bulletin, a century after the actual event.

            “‘A Matter Of Extreme Urgency’ Theodore Roosevelt, Wilhelm II, and the Venezuela Crisis of 1902.

            http://www.theodore-roosevelt.com/images/presidentpics/venezuelacrisis.pdf

          • Rob Burnside

            Thanks again, Ninguem. All in all, I doubt there’s a more fascinating period, or individual, in U.S.History. About the time this happened, my grandmother was riding a horse to and from Hazleton Miners’ Hospital, training to become a nurse.

            To earn her cap, “Nana” had to move to Bryn Mawr to care for female and pediactric patients. Bryn Mawr Hospital had one of the first ambulances in the country. Nana became a driver and was later dispatched with the ambulance to New York Harbor to meet the “Carpathia” bringing survivors from the “Titanic” into port.

            She never spoke of this, and I only learned about it after her death, going through some old photos. Something tells me she and TR would have gotten along swell.

          • DoubtfulGuest

            South Chicago, huh? I bet I know where you mean…that’s where I had part of the bad experience that hangs over my head to this day. I also saw one really excellent doc who did what she could. I’ve always felt safe in Chicago though, on the streets, evenings included.

            So yeah, I can understand what you’re saying. This article is really troubling, especially that quote. And re: your experience, the fact that people couldn’t even get from their workplace to their cars safely says a lot. You guys’ cortisol levels must have been off the charts. I’m no fan of guns but I can’t know how I might feel if I lived in those conditions.

      • DoubtfulGuest

        Hey RB…Did you see Margalit’s brochure draft just added an hour or so ago? Thoughts, input, feedback, questions, complaints, compliments, suggestions, raspberries? She’s put a lot of work into it, and it’s only Sunday.

  • Patient Kit

    In the name of transparency, docs should admit that they don’t have to spend any money on lunch since they don’t have time to eat lunch. That might combat the myth that docs eat better, yummier, more expensive lunch than patients every day.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      S10: Working conditions, benefits, meals, hours

  • toolate

    I didn’t know till that release how much Medicare paid for my services since they were billed by the hospital. I learned that for treating a complicated psychiatric patient on an inpatient unit, with questions of danger to self and others, with a mix of severe mental illness and substance abuse and often medical problems, with going to court, etc.. Very stressful work. Work conditions were bad, too. Horrendous EMR. Abuse by nurse manager. The usual. Noce co-workers and Med Director, unusually. Filthy office, never cleaned.

    And you know how the public is always going on and on about ‘something needs to be done about mental health’? Well, this place where I worked was the line of last defense. OK?

    Anyhoo, for this, I REAPED (before expenses) a whopping THIRTY dollars per pt per day.

    I then looked what Medicare pays for output. visits to psychiatrists. Twenty to thirty bucks IIRC, don’t feel like looking it up again. Before expenses, of course.

    That’s what psychiatrists are worth.

    • B Viner

      That’s depressing.

      • toolate

        If you wish to discuss your feelings, give me the full $20 for my time. Upfront, cause I’m greedy and uncaring.

        • B Viner

          How much time does $20 get? As long as I can talk about my mother and father and walk out with a prescription for Prozac then it’s a bargain.

          • toolate

            If I were a lawyer, let’s see…at 350/hr you’d get 3.4 minutes.

            If you’re a psychiatric inpatient, you could get several hours for that! Come on over, door’s open (on the way in at least).

          • B Viner

            If you were a lawyer, you’d charge me for corresponding to this post. Where do I check in?

          • toolate

            From where you are (per your posts) – LAX or SFO are the doors Into The Asylum.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      That explains why many psychiatrists don’t accept insurance, and why trying to get a referral to pshyc for Medicaid kids is practically impossible, according to pediatricians around here.

      • toolate

        It’s the paperwork and the demeaning bureaucracy AND the pay. I think Medicaid is even less than Medicare.

        Keep in mind that in my specific case we’re talking sometimes about treating the next potential shooter, and the psychiatrist’s decision, can he go, or not. Thirty bucks.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          How can the hospital afford to offer any services?

          • toolate

            No idea. But there’s no money for proper medical support from other specialties, for example. And who’s fault would it be if something happened?

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Not sure…. some childhood trauma or society or some other nondescript factor… ?

  • B Viner

    Exactly! Eerily similar to something like fee for service. Maybe we could even offer a discount or refund if not 100% satisfied. The last sentence was tongue in cheek, but I agree with your above paragraph wholeheartedly.

  • B Viner

    Agree. Transparency is only allowing you to see what they want you to see.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Transparency in this particular context is a cruel joke, or just another term that means the opposite of what the intention is. We have lots of those lately.
    In my opinion this has little to do with the fall elections, or maybe I fail to see how. It has a lot to do with the general strategy to minimize whatever “power” CorpMed thinks doctors still have.
    When you look at what CMS pays each doctor, it is easy to discard as insignificant. When you look at the sum total, you’re talking about tens of billions, which CorpMed would love to get its hands on. So step 1, is to create public sentiment that doctors are overpaid. Step 2 is to push regulations to bring those payments down to more “reasonable” levels. Step 3 is to pocket the difference, because I guarantee that not one red cent will be flowing back to taxpayers. The government is just serving its masters.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Yes, it would be very enlightening, to say the least, but sadly CMS did not publish that data… I am not holding my breath…

  • JR

    I looked up the release and it seems my PC physician sees his medicare patients 3 – 4 times a year… the same as his other chronically ill patients. Interesting but certainly not mind blowing.

  • DoubtfulGuest

    The scooters. Why would anyone not want to walk while they still can?

    • John Henry

      “Free” stuff. Lazy. Why do ambulatory people (OK, maybe large but still ambulatory people) choose to ride the carts around WalMart when they could walk faster?

      • DoubtfulGuest

        I’m asking about people who can walk without pain. It can be a vicious cycle, of course, with deconditioning, but I feel compassion for people who have untreated problems that affect their walking comfort. I have a neuromuscular disease and I walk a lot while I can. I feel worse if I spend much time in the car. I was just venting…I get tired of healthy people asking why I walk so much. :/

        • ninguem

          Doubtful……..”I’m asking about people who can walk without pain”

          Everything you said is true, with respect to deconditioning and all that. But they wanted them anyway.

          Ask any doctor in primary care, that sees seniors.

          We get badgered CONSTANTLY for those damn scooters. Those scooter companies whipped the seniors in a frenzy and sent them after the doc to sign off on the forms, and we had to be the bad guy to say no.

          I had many angry seniors…..MANY angry seniors, who went elsewhere over those scooters.

          And I’ve been audited over the appropriateness of the scooter orders. Audit means, Medicare is trying to charge me with fraud and abuse.

          Fortunately, many of those companies got shut down.

          The dollar figure was about three-quarters of a BILLION dollars annually for those things.

          • DoubtfulGuest

            Fascinating. I knew nothing about this until reading this post. Can’t blame you docs for being frustrated. The audit thing is just crazy.

            I try not to judge individuals I see, because so often it’s impossible to tell what’s really going on with a person just by looking. I was just thinking a scooter sounds like the last thing I’d want. Like you say, a recipe for disaster, health-wise. For a little while, I tried driving more often, the short distances, to save energy. I found my muscles were getting kind of stuck in that position, it got harder to stand up straight, I felt awful. And I was getting short of breath more easily. I don’t know yet what it feels like to get old, I just can’t imagine being healthy most of my life and not trying to keep it up.

            No docs reading this get any ideas, okay? But one time I was very upset after a doctor visit, and I walked exactly five miles back home. I just couldn’t stand still to wait for the bus (car ownership has been off and on for me). By the time I got all the mad out, there were almost three miles yet to go, in a not very pedestrian-friendly part of the city.

            You are THE source for educational images around here, Dr. ninguem. I’ve previously seen a…collection…of Victorian medical paraphernalia, so this part of the story is not so surprising. The fraud and waste, though, with DME, is a new perspective for me.

            What do you think of this ‘info brochure’ proposal then? Could it be helpful if done right, or do you think it would only keep docs on the defensive and the public’s focus off where it really needs to be?

          • ninguem

            Assuming the senior gets the scooter. Well, no one lives forever. And the scooter may well accelerate the senior’s demise.

            In any event, you can’t take the scooter with you. So, you would think there would be a secondary market for used scooters. Clean it up, new upholstery, fresh battery, tune the motor, someone else could use it.

            But you virtually never saw used scooters on the market. Why, just get another one. Medicare paid……..you could get a golf cart or a used economy car for what they paid.

            The grand-kids would play with the scooter until the batteries went bad.

            Then, off to the landfill.

          • ninguem

            DME = durable medical equipment.

            DME fraud. Not that long ago, you could simply call yourself a DME company. Set up a mailbox with UPS store or similar.

            Doubtful Guest Medical Supplies. 123 Main Street, Suite 456, Podunk USA.

            Get lots of names, Social Security numbers. All to easy to get.

            Send a big gang bill for DME. Nothing big, that gets their attention. No scooters or those electic butt lifters from the chairs or walk-in tbs, none of the things that would get scrutiny.

            Canes. Braces. Manual wheelchairs. That sort of stuff. Send in a big gang bill for all the stuff. Lots gets denied, lots gets paid.

            You get the check. Close the mail drop.

            By the time they audit, you’re history.

            They closed that commonly-used trick. In so doing, they also shut down legitimate physicians who wanted to dispense for those things.

            Now I can’t. I would send to the DME shops, but they’re too busy trying to upsell the seniors on the walk-in tubs and chairs that go up the stairs and the things that lift your butt out of the chair.

            The Office of the Inspector General = OIG.

            The OIG inspects all sorts of things in the Federal Government of course. Healthcare, needless to say, is a big part of their work.

            Go to the OIG “Exclusions Database”. People excluded from Medicare and Medicaid participation.

            You can cross-reference against name, or line of work (physician, nurse, chiropractor, pharmacy, etc.).

            Taxicabs that give Grandma a free ride to the liquor store and bill Medicare for a ride to the hospital.

            Lots of doctors are excluded. The main reason is they lost their license. Can’t bill Medicare if you can’t practice Medicine. Other reason is failure to pay student loans. You’re back in as soon as you’re paid up.

            For “program-related” matters (read = fraud), it’s usually business entities, which may include physicians ACTING as administrators.

            Because practicing physicians can only rip-off Medicaid “retail”.

            For big “wholesale” fraud, you need a business of some sort, and a plain old medical practice is usually not enough.

          • DoubtfulGuest

            Doubtful Guest Medical Supplies. 123 Main Street, Suite 456, Podunk USA…I like it. It just reeks of integrity, doesn’t it?

            I will check out this database…I had no idea what you all have to deal with.

          • DoubtfulGuest

            I am a crazy environmentalist, and accomplished thrift/antique shopper. I have never seen a used scooter for sale. Good point.

          • ninguem

            “…..You are THE source for educational images around here, Dr. ninguem…..”

            Thank you. YES, the subject has been studied historically.

            http://www.magicbluepill.com/museum/images/crank_pump.jpg

            http://4.bp.blogspot.com/_ByccNJa0ui8/TKFMT9Mt1bI/AAAAAAAAABk/-IPKVtZ5lJ4/s1600/8.jpg

          • ninguem
          • DoubtfulGuest

            GACK!!! And psychomd was worried about crashing Margalit’s party…Right-o, this is a low-tech thing that shouldn’t cost hundreds of dollars. So, should this go in the brochure? Were you pro- or anti-info brochure, now? I’m guessing you vote “no”? ;) Are you docs unaccustomed to brainstorming sessions, by chance?

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            I wish more people would “crash” this party (see my comment in response to psychomd)….
            Anyway, those pumps go for about $125 – $200 online and in 2014 Medicare is paying for L7900, which is the pump, between $450 and $600. Leaving aside the question of whether taxpayers should pay for this stuff, why should Medicare, which seems to be buying huge amounts of the stuff, pay 4 times retail?

            Here is my S15: We will need a lot more than one brochure. Maybe an informational series on various subjects. If we make it too long or lose focus, people won’t read any of it in this “infographic” era…..

          • buzzkillerjsmith

            DME, drugs and hospitals is where the real money is made. But they have lobbyists.

    • Patient Kit

      I don’t understand the prevalence of the scooters either. At least, with a regular wheelchair, you maintain upper body strength. When my femur was fractured for two years, I swam regularly and hobbled around the streets of NYC, on a walker, then crutches, then a cane, until I healed. I could swim a mile when I could barely walk. Thankfully, no external cast on that femur

      I did the same when I was rehabbing from surgery to repair a badly ruptured Achilles tendon. Once I was out of the first two hard ankle casts and into the boot, I took that boot off poolside, got in the pool, swam laps, got out of the pool, put the boot on, went upstairs to the showers, took the boot off, showered, put the boot on, hit the street, got on a bus.

      I was always acutely aware that, if I wanted to regain my strength and mobility, I had to move and exercise as best I could while healing. Lots of people told me I was crazy — that if they were me, they would just sit on the couch for months. To their credit, my docs all encouraged my swimming. And I still swim a mile 5x a week and am walking pretty well, all over NYC. Swimming is a total addiction.

      I’d take my own pool over a scooter any day. I do understand that some peeps can’t get around without scooters. I think there needs to be strict criteria on who needs them though.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    S12: Charts for price composition and differentials

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Here is what we have so far:

    S1: So we have the EOB – a simple explanation of charges vs contractuals/allowables vs patient responsibility, and why these are different numbers…. simple (and funny) being the keyword – and how by definition this makes things more expensive
    S2: Explain why charges are so much higher across the board and whether those are real for anybody.
    S3: Doc’s expenses on things perceived as caring and positive by patients, such as health insurance for staff.
    S4: Highlight insane complexity of how payments are decided by CMS
    S5: Highlight cost of complexity and lack of transparency
    S6: Overhead (utilities, payroll, insurance, supplies, rent, professional fees….)
    S7: Student loans for med school are larger than most
    S8: “If we do something for you and don’t see you, we don’t get paid.” Remember no-shows…
    S9: Rural medicine – maybe we need several versions of this brochure…
    S10: Working conditions, benefits, meals, hours
    S11: Should this contain “real” data or just general notions, averages and such?
    S12: Charts for price composition and differentials
    S13: MOC

    There are several formats we can consider:
    1) A trifold brochure – has 6 very narrow pages – the front and back should be devoid of heavy text, which leaves us with 4 strips of about 2×7 for content. The front page should have something provocative on it to induce people to pick it up (I assume it would be placed in your literature rack….). If we do this, we will have to pick the most important things to convey, accounting for large fonts and graphics. Can be downloaded, printed and folded in the office.

    2) A pamphlet format, which is like a tiny booklet, with more room and more pages. Same design constraints but more pages. Unlike the trifold, this will have to be professionally printed and bound.

    3) We can do both and let people choose what to use. Should we start with the booklet or with the trifold? If we can distill the heart of the argument, the trifold will be faster and more likely to be used. The pamphlet may allow us to make a complete argument….. Hard choices :-)

    Remember that the audience is lay persons, perhaps too sick too care, including elderly and financially challenged….

    Thoughts?

    • DoubtfulGuest

      Any idea of costs for Option 2?

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        It depends on how many pages and where you print it. At Kinko’s it’s about $1 per color page, exclusive of binding.

  • Deceased MD

    Great piece Margalit. Spot on as always. The problem is how does one defend themselves when the spot light is on docs not on the” real” money (or majority) for HC?
    I guess there are many questions, but the one I would ask is why does medicare allow itself to be taken advantage of? (LOL It’s even in their name now)! We have laws that medicare cannot negotiate with Big Pharma. Ninguem mentioned the lists of scooter stores, endless DME (durable medical equipment) that the costs are shocking. I mean shocking. Some of these things can be bought for a quarter of the price and the mark up is jaw dropping.
    The problem that you point out is it puts docs in a defensive position. And if we finger point, well that must be why.
    But if you are thinking of a pamphlet or an article, compare the costs of DME’s that are made of plastic and cheap to make. See what medicare pays. See what Medicare pays as the rate of drugs is non negotiable. And then compare a PCP visit cost to that poor psychiatrist toolate who gets $30 for people that are potential menaces to society-not to mention a possible danger for toolate).
    I think a smattering in every category of the crazy prices paid for medicare to Big Pharma, hospitals, DME’s and the $30 visit for the psychotic homicidal maniac in toolate’s ward.
    If these costs are not transparent, some are not hard to find out. I learned the hard way and went myself to a medical supply store and they will tell you what medicare pays them. that’s how I found out that these plastic devices to stretch the ankles, medicare at the time paid $400 so that was the cost. Amazon was $55.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      All good points as usual…
      S14: Compare doctors pay with other Medicare misguided expenses (DME)

  • buzzkillerjsmith

    Hi M, Well done.

    Your last paragraph is key here. A word to the wise.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      Thanks buzz. If we actually do create a free printable/shareable resource library in the public domain, do you think anybody would bother with using any of it?

      • buzzkillerjsmith

        Maybe a few but we’re basically in an echo chamber here. Most prefer Duck Dynasty and ultimate fighting.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Oh, you are not at all crashing the party. It’s not my party anyway…. it should be your party :-)
    I am actually learning here, so I am beginning to think that you would be better served by having a series of informational materials created (a narrative of sorts), because there is no way to pack so much angst in one miserable brochure…. so thank you for the insight….

    • DoubtfulGuest

      Yes, a very informative thread. I wish more people would jump in, too. The whole point of this is to meet a need for doctors, save them time and angst in discussions with their patients when these questions come up. I have seen lots of info-series brochures in health care, e.g. at university clinics. More effort, but likely better results.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Update: So I made a draft for a little trifold brochure
    https://drive.google.com/file/d/0B8BeVx5dHnjfRGREXzlFTGNRVE0/edit?usp=sharing
    I’m not very happy with it, but wanted to illustrate the ideas we gathered here.
    What bothers me most is that the inner pages are way to dense with text. And it doesn’t even include all the Suggestions we have here.

    If we are serious (are we?) we will need to think about a series of lighter materials…. or maybe a different format.

    Thoughts, comments, ideas…. what do we do next, if anything at all?

    • DoubtfulGuest

      This is really quite nice as a first draft. Thanks for putting in the
      time.

      At first glance, image-wise, I think some graphics of a
      perplexed-looking person with pockets turned inside out, floating dollar
      signs, arrows, thought/idea balloons, that sort of thing, would help
      lighten it up. The ones already there look good. I could help track down some free clip art that might be applicable?

      Maybe a more flow-chart kind of presentation heavy on the
      graphics would be helpful? And I liked Arby’s chart ideas. But then that would require more space. I like the text explanations, the “trivia”, etc. It’s a great start, at least. For Medicare “medium-sized” visit, is that time or complexity?

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        The problem I have with graphics is that for every graphic added some content has to go. Putting content in graphics in such a tiny space will make it unreadable. That’s what happened when I tried Arby’s charts. If you look at similar trifolds for other things, you will see very little text by comparison to this one. We just have too much to say, I guess :-) It doesn’t have to be one shot though…. This format doesn’t lend itself to complex ideas. I’ll keep looking, but if our esteemed friends here don’t kick in, it seems that this entire project serves no purpose….. We’ll see…..

        • DoubtfulGuest

          True, I was thinking if we went beyond a tri-fold. But then there’s the cost issue. I personally would not be put off by the amount of text in your draft.

          General questions: when medical offices do print and provide literature, what kind of volume are we looking at? How often do they need to replace stuff as opposed to people just glancing through like the magazines? Are there usually minimums of 50, 100 copies, or what?

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            The way I did this in the past (in a different context) was to email the electronic file to the practice and let them print (and fold :-)) as needed. They can do this right there in the office.
            Never had so much text in these things, and remember that literacy levels vary greatly, and so do levels of interest.
            So you have to try and grab attention right away, by any cheap means necessary :-) (like click bait online, but for a good cause…)

          • DoubtfulGuest

            Agree. 1) If tri-fold is best to save money and keep it simple and 2) many graphics aren’t feasible, would it be true to say we’d need more white space and to prioritize the information? I thought page 1, far left column and page 2, far right column were maybe the most interesting and valuable. But I don’t exactly have my finger on the pulse of what the general public likes. ;)

            What about the trivia part only, just to get people thinking…but more of it? Or is a series of tri-folds with different topics still an option? Well, I’d better get back to work, and should wait to see what others say, but please let me know if I can assist in the meantime…

  • SteveCaley

    God help us all. I fear Kristallnacht against the small stand-alone clinics, the very ones that are the least concerning. I never thought I’d say that in America.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Yes, I agree with this and the earlier comment you made. There should probably be several shorter brochures and plain text + graphics versions for updating practice websites, and maybe even small poster-like pieces. A good campaign should have several types of collateral, from short and catchy to whitepapers and opinion pieces to hit all notes at once…. There should also be a website to distribute these things (I bought hcfacts.org the other night – I keep getting ahead of myself on stuff like this, so I have a nice collection of domains :-)
    Unfortunately, it doesn’t seem like there is too much interest in concrete actions…

    • DoubtfulGuest

      Oh, crumb. I’m disappointed to see no new suggestions today. You shouldn’t have to work harder until you get some more assistance. Perhaps next time. Hey, it was exciting to see brainstorming this round, and a real draft on Google Drives! Baby steps, I guess?

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        Yep :-) One of these days we’ll have Unicorns grazing in Central Park….

    • Arby

      Build it and they will come? I don’t know.

      I wouldn’t invest any money or in creating more than one finished piece until I saw how that went over. The website part of it interests me, yet with my current schedule, I can only provide moral support at this point.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        They won’t come…. :-) I think I’m done for now.
        I’ve been down this and similar roads several times before. One of these days I am going to learn how to keep my mouth shut…. :-)

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