Saturday, August 22, 2009

Health care reform - Will anyone hear my suggestions?

How I wish I had access to someone involved in the health reform process in Washington!!

I would slip them a memo with just a few provisions suggested, they would take the memo, take the suggestions, and just slip them in as provisions to the health insurance reform bill that comes out. It wouldn't be hard, they are just a few things that would make life a lot easier for doctors, if only I knew someone.

On a much smaller scale, I did it once before. Here's my War Story. (Then after the War Story is the memo I wish I had someone to deliver it to.)

After my internship I worked in D.C. with the Public Health Service, as a so-called "two year doctor." It turned out I stayed in the USPHS for six years because I liked it and got a great deal, but still, I was a two year doc. In the second year I became head of the Migrant Health Program for a year. What a mega-experience! Especially since halfway through the year we got a surprise additional appropriation that we had to spend in just a few months, and I was in charge. Not only did we get the money spent, but we changed the whole concept of the program, away from giving small grants to county health departments all along the so-called migrant stream, and instead establishing significant health centers that would cater to the migrant workers, rather than simply working them in as another duty of the health departments. To do this we had to get all our regional offices activated to find grantees, and I myself went out to the field and wrote a grant in Orange Cove, CA, then flew back to DC, received the grant I had written, and approved it. A lot of fun.

By that time I really knew a lot about health care policy and probably as much about migrant health care as anyone. My father said, Budd, you ought to write a book. My Dad. He found me downstairs at his house reading "Ball Four" by Jim Bouton instead of doing the book and said, "You should be ashamed." My father.

But, actually, while he wasn't right about my being ashamed, he was right that I ought to write a book. So I actually did. First I got my Masters degree at the Graduate School of Public Policy at Berkeley. I wrote the first chapter as my Masters thesis, promising more to come. The next year I spent at the Stockholm School of Economics, and in between learning Swedish and doing research on Swedish health care, I finished the first draft of the book that was eventually published in 1975 as "Health Care for Migrant Workers - Policy and Politics."

But before it was published, I thought that to really finish the job, I ought to see if we can get the Migrant Health Law changed so that the policies of large health centers would be mandated, and couldn't be reversed by the next denizens of the Public Health Service Migrant Health Division, with their long standing ties to county health departments. It happened that I could co it, because I had one more year in the USPHS, and I was going back to Washington. I wasn't supposed to be lobbying for anything, of course, that wasn't my job. But I was in Washington, I was young, it was the 70's, and that's just me, anyway.

I think it was my friend Jim Mongan, who was then a staffer on the Senate Finance Committee, who got me in touch with Brian Biles, who was a staffer for Bill Roy, MD, Congressman from Kansas, who was on the House Commerce Committee, with jurisdiction over Migrant Health. I showed the manuscript, which was hefty, to him and to Steve Nelson, I think his name was, staff aide to Paul Rogers, Chairman of the Committee. They heard my rap, they weighed the manuscript, Mongan had probably told them I was a smart, good guy, and they thought it made sense. So they ran with it. They wrote the bill with my help, and got the adherence of Bill Roy and Paul Rogers.

Ah, the good old days! The bill was about to be passed and there were final hearings. I wasn't supposed to be there, of course, but I went to the final hearings where Paul Rogers presided. I was there in the audience trying to keep a low profile. I'm not sure who else was there, but the old guard of the Migrant Health Program who had worked all those years with county health departments and shipped them money, to whom I was of course anathema, had to be there, too. I kept a low profile.

So, naturally, at the end, with the new legislation going to be passed, what does Paul Rogers do? He looks out in the audience and says, "Now, where is Budd Shenkin?"

I am aghast, I'm not supposed to be there, I wasn't supposed to do this, and I'm saying to him silently and with my hands, "No! Don't call me out!" But he mistakes my reticence to modesty, and says, "No, come on, stand up there! This young man has done a real service in ... ." Actually, I'm not sure what he said. I just reluctantly stood up and took a small bow to scattered applause and sat down and hoped no one really noticed.

I needn't have worried - after all, what were they going to do to me? I was leaving the next year anyway, and besides, no one pisses of Congress if they can help it, and I was their guy. Even today, by the way, the law prevails, and the health centers that we established still exist.

The whole thing, and especially that day at the hearings, sticks in my memory as one of those things we remember to the end, a mile marker. (Like the time I came in to the first JV basketball game of the season with two minutes to go and the score tied, and scored five points and had an assist and we won and finished the season 23-0 -- but that's another story.)

Anyway, we could do that in migrant health. It was a very low profile program, no press whatsoever, no powerful interest groups, virtually nobody watching, something you can kind of slip by. Brian and Steve and I did high fives and they said, it just goes to show what one squirrly guy can do if he sets his mind to it, and I thought they were great. We gloried in our accomplishment. In their world of Washington congressional aides, doing good was the equivalent of making money on Wall Street - or probably Main Street.

Health Reform couldn't be any more different from Migrant Health, of course. Everyone's watching. Still, I wish I had friends like Steve and Brian now. I bet we could just slip some stuff in! I'm no longer with the USPHS, and what I know now is different, since I have been a practicing pediatrician for thirty years (where did they go, one asks.) I've been dealing with health insurance for a long time. So, if I could, here are the little changes I would make. It is in a memo I wish I could slip to someone who trusted and respected me, as Brian and Steve did, with just a couple of provisions to control what the health insurance companies do. I so wish.

Here is the memo:

Health insurance reform is sorely needed. The first consideration has been the interest of the American people at large, many of whom are priced out of the market, or are subject to untoward restrictions on policies, or are subject to rescissions. The proposed Health Insurance Exchange, which entails many requirements on insurance companies to repair these problems, will remedy many of these problems.

Less prominent in the discussions, however, has been the fact that physicians face some of the same problems in dealing with the insurance companies as the public does. Physicians frustrated by these insurance practices, and they contribute to the notorious lack of efficiency of the entire system. Physicians and insurance companies alike have small army of employees who spend their time determining eligibility, determining co-pays and deductibles, coverage for specific services, submitting claims, rejecting claims, appealing claims, etc. These opposing armies fight over money and rack up overhead dollars to the ultimate advantage of neither, and to the disadvantage of the public.

The Health Reform legislation should and could address many of these problems of insurance company/physician relations at the same time as they address the insurance company/patient difficulties. Here is a small set of measures that could be easily entered into the current legislative proposals that would increase simplicity and decrease overhead on all sides.

• Eligibility determination. When a patient makes an appointment, the physician’s office needs to know if the insurance coverage is current in order to know how to deal with the patient. At present, the insurance companies maintain websites with lists of eligible patients that the offices can access, but which is sometimes out of date, and which often does not detail all the specifics of each policy. A physician office thus has to access the site for each patient appointment and guess at some coverage issues. If the website indicates incorre tly that the patient is eligible, the physician’s claims are rejected because the website data was not accurate. Solution – legislation should mandate that insurance companies maintain eligibility data in a standard format, and that software be supplied to physicians’ offices so that all the offices need do is submit name and birth date, and all relevant data will appear instantly. The insurance companies should be required to honor physician’s claims if their website data was inaccurate. This provision could be called instant verification of patient eligibility.

• Payment standardization. Physicians are required to submit bills according to strict rules of CPT coding. Yet insurance companies are free to ignore some billings, saying that they regard these services as “covered” by other codes perhaps, or just saying that they simply choose not to pay those codes. Insurance companies should be required to respect all official CPT codes and policies that an office bills.

• Prevention of false billing. Physician offices are not pristine; over-billing does occur, and it can be difficult for an insurance company to detect. Currently, the insurance companies frequently demand to see copies of encounter notes before paying bills, and frequently down-code visits presumptively. The result is a never-ending exchange of data, denial and defense, delay and consequent overhead escalation. As a remedy, insurance companies should be allowed to request encounter data on 2% of an office’s billings per year, and to pursue cases of over-billing only if this sample provides evidence of persistent errors.

• Standardization of code submission. Much of CPT coding regulations are straight-forward, but some are not. For instance, if an office does a screening test for postpartum depression, there is a standard CPT code to use, 96110. Some companies will accept the code as is, others require a modifier, and yet others require a different modifier. The physician’s office then has to remember which code goes to which payer, and when small errors are made, resubmit claims after a denial is made. Standard industry-wide policies for code submission should be established.

• Extension of timely filing. It is easy and common for insurance claims to be sent to the wrong address, because patients frequently change insurances, and many insurance companies have various addresses to submit claims to. Rectifying an incorrect address can take time, and when the bill finally arrives at the proper address, it is sometimes rejected for untimely filing. The insurance company should be required to pay the claim if proof can be produced that the claim was filed timely somewhere. In addition, the same requirement should hold if the original claim was somehow defective, even if sent to the proper address. A service properly rendered by the physician should be honored.

• Establishment of an administrative ombudsman. Disputes and misunderstandings are inevitable in the relationship between insurance companies and physicians. In addition, improvements will always be possible. Just as some proposed legislation will establish an ombudsman for the public, legislation should also establish an ombudsman for insurance company/provider relations. In addition to fielding complaints, the ombudsman could be a watchdog for this area, and recommend progressive steps to increase efficiency and fairness.

• Establishment of fair vaccine payments. One of the most important aspects of prevention is the administration of vaccines. Yet, insurance companies frequently pay for the vaccines barely at cost, leaving the physician to eat the cost of overhead. Similarly, the Vaccine for Children program (VFC) provides the physician offices with the vaccine but does not pay for overhead. Insurance companies should be compelled to pay for vaccines at a fair rate, which has been calculated to be about 125% of Average Wholesale Price of vaccines, plus the administration fee. Practices providing VFC vaccines to patients should be paid the same overhead rate as they are paid for commercial vaccines, since the overhead for commercial and VFC vaccines is about equal.

• Establishment of competing Public Options. The provider community has objected to a Federal Public Option because of the disproportionate power to price and contract on the side of the Public Option. If, however, each area were to have at least two alternative Public Options – Federal, state, and/or coop – the competition among public entities for provider network members would decrease the imbalance of power. This approach has been advocated by Mark Pauly of the Wharton School.

Of course there are many other provisions to health insurance reform that would help to streamline the system and make the insurance company/physician playing field more level, but I would submit that these incremental adjustments (except the Public Option provision, which is not incremental) would be rather easy steps forward.

Oh, how I wish.

Budd Shenkin


  1. I counter your blog length with brevity:

    Right on! I'd quibble on one or two points here, but your suggestions above would do more to reduce health care costs - at least in our mutual world - than anything I can think of. Well, maybe the abolition of corn syrup.

  2. These are great ideas. Have you tried the old fashioned route of sending them to your congress person?