Vaccines may be saving the lives of children, but they are killing the docs who give them. Pediatricians have to pre-purchase tens or hundreds of thousands of dollars of vaccines, insure them while they sit in the fridge, and then are often paid at or less than what they paid for the vaccines themselves when administered weeks later. If a mom changes her mind after the imm has been drawn or the kid fights it - there's $75 down the drain. Gardasil is a great example: many insurers still don't cover it fully! - so the practice is supposed to eat the few hundred bucks? Or, how about the flu vaccines? Patients fill the phone lines of the offices looking for a shot...that the docs can't fill until after the rush is over...meanwhile, Wal*Mart and the retail clinics often got their deliveries on time.
That just makes no sense. Enough pediatricians are feeling the pinch, however, that we're seeing movement. One solution is to check out the numerous vaccine buying collectives (Physician's Alliance, Pediatric Federation, and Main Street Vaccines come to mind).
To the AAP's credit, this is one issue they are doing something about. I just hope they can do something in time.
Meanwhile, here's a summary of the problem from the latest issue of Infectious Diseases in Children. It provides more data to match the vignettes from that NY Times piece from a few weeks ago (featuring PCC clients and friends alike). In the IDC article, they recommend:
- Fix vaccine administration fees; this includes collecting data on the costs of delivering vaccines in private practices, getting support on methodology from the Centers for Medicare and Medicaid Services and using the data to educate insurers and Medicaid on appropriate reimbursement.
- Work with vaccine manufacturers to obtain more favorable terms for the initial inventories of new vaccines.
- Work with federally qualified health centers to delegate authority to serve underinsured children through the Vaccines for Children Fund at public health department clinics.
..which is a pretty good list, if you ask me. Yes, there are other changes I'd recommend, including:
Frankly, I think it would all be easier and more appropriate if all vaccines were VFC. That will never happen, though, as long as the pharms can make good money.
I have to come up with an analogy for the Great Medical Insurance problem here in the US. The Rebels vs. The Empire? Robin Hood vs. The Sheriff of Nottingham? David vs. Goliath? None of these is just right, but they each contain elements of the issue: a giant, controlling source of pain and trouble being fought by the little guy (or woman - see below). It's a matter of time before we see the Erin Brokovitch movie about the insurance industry.
What a delight it was, then, to read this month's SOAPM newsletter (past issues are available at the AAP as well as at PCC, as we sponsor the newsletter). First, I read Dr. Francis' piece reminding pediatricians to go to hmosettlements.com to participate and keep an eye on the settlements with Aetna, Healthnet, Wellpoint, Humana, and Cigna. Just go read the entire site.
Even better was the description, from Dr. Stoller, of how she discovered Aetna was in violation of their settlement terms and, through just a little work, was able to recover a significant amount of income relating to -25 modifiers as well as mis-processed "out-of-network" claims (that were really in-network). As she says, "FIGHT BACK!"
Then, I got the email:
Good work. My favorite part of the email reads as follows:
This latest national class-action settlement is one in a series of actions against major healthcare insurers and another milestone in the check against widespread and chronic abuses against physicians. These class-action lawsuits have resulted in significant reforms in the health insurance industry.
The settlement consideration includes a guaranteed cash payment of over $128 million to class members. In addition, the settling defendants have agreed to implement important business practice changes that will bring the estimated value of the entire settlement consideration to well over $1 billion.
Perhaps an Austin Powers analogy would work? "One Billion Dollars."
It gets better, though:
The agreement follows similar settlements with other major managed care companies, with the exception of United Healthcare, who continues to litigate against physicians rather than making the kinds of positive practice changes other insurers have agreed to make.
Indeed, United Healthcare has repeatedly refused to address the significant concerns raised by representatives of the more than 400,000 physicians nationwide who care for United Healthcare's members. According to MSNJ CEO & Executive Director, Michael T. Kornett: United Healthcare simply has not raised its standards to what has become the industry standard in healthcare. United Healthcare has systematically engaged in practices of coercion and intimidation that are akin to the actions of a school-yard bully. When all the other major national healthcare insurers agree to conduct business with their physician/providers in a more transparent and fair manner, it is difficult to understand why United Healthcare refuses to operate on a more level playing field.
Wow. Although I assume it actually isn't difficult for anyone to understand why United behaves this way, kudos to the Medical Society of New Jersey for stepping up.
I always forget to leave notes about where we are going to be and what we're doing when we get there!
* NEW PCC Pediatric Solutions Workshop in Las Vegas, May 20
Put your practice ahead of the curve with expert guidance from
PCC. PCC's Pediatric Solutions consulting group brings their
expertise to you through affordable, convenient workshops around
the country in 2007. Pediatric Solutions Workshops focus on topics from
coding practices to insurance negotiation assistance.
Join us on May 20 at the Venetian Resort Hotel in Las Vegas to
increase your revenue through effective patient recall strategies.
Increasing well visit volume and managing chronic diseases among your
patients is crucial to both the clinical and financial success of your
practice. During this discussion, you will learn about proven recall
techniques used by pediatric offices across the country to augment your
marketing, manage your patient appointment volume, and improve your
To learn more about this and other Pediatric Solutions Workshops,
and to register, go to www.pcc.com/practmgmt. Registration fee is
only $75 per person and space is limited.
* What happens in Vegas?
For your convenience, this event begins just after the AAP
California Chapter 2 Advances In Pediatrics, 18th Annual Las
Vegas Postgraduate Meeting, and is located at the same venue.
I've always enjoyed this show, Vegas notwithstanding. I hope to get a
good turnout at the workshop, but we haven't been great at advertising it.
Unless you are the king or queen of coding, get yourself to NYC on Aug 22, the day before the big PriMed NYC event, and see for of the heaviest hitters in pediatric coding matters. From the release:
This is an intensive, one-day session focused on important pediatric issues that effect your practice every day. You'll master the coding basics, get answers to your specific questions during Q&A sessions with our pediatric panel, and gain valuable insight on timely topics about immunizations, pay-for-performance programs, physician compensation, and more. Our expert panel of instructors include AAP Fellows Richard Lander, MD; Chip Harbaugh, MD; Joel Bradley, MD; and Richard Tuck, MD.
I'll be there, too! Sign up and get what you deserve. Class titles include "Who Wants to Be a Coding Millionaire?", "Give Me The Money: How to Collect Your A/R", "The Codes You Miss", "Pediatric Physicians Compensation Models" and more.
I have grand plans for a series on pediatric benchmarks. Tim and I have been working feverishly on a series of WWW-based tools for our clients and our hands are dirty with all sorts of tidbits that I hope to share.
If I were smart, which I am not, I would start small and build up a series of benchmarks, culminating in an overflowing abundance of pediatric data that the world has never seen. But, like I said, I'm not smart, so I'll just jump into one thing I found fascinating:
...I'm sneaking in a bunch of benchmarks at once, so read closely.
First, you get the average charged, per visit, by PCC customers (the pediatric ones) in both 2003 and 2006. Then, you get the average revenue/visit for both years. This is gold in the benchmark business.
But we took it a step further and removed the revenue that comes from immunizations. Not the admins, just the vaccines themselves. This allows us to compare practices who purchase everything to those who purchase nothing (like VT pediatricians) and the majority, who are somewhere in between.
What do we learn?
During my travels, I have had over a dozen new insurance updates/stories/foibles forwarded to me, 90% of them originating with United Health Care. I'll toss some up, of course. I can't wait for United to find this blog, even though it's so benign.
Rather than harp on UHC, though, I thought I'd tell two quick, nice stories.
I looked at the prices and they look, well, great. As the doc pointed out, they offered more for their 99213 than the practice even charges! What's nice about this second HMO is that they actually approached the practice. They are looking to expand and identified client #2 as a good choice - how great is it to negotiate before signing the contract? BTW, for those of you living in places like Atlanta, Tulsa, NYC, etc.: getting 130% in most parts of this country is really good. Getting it on Long Island, where this practice is from, is crazy talk.
For some time, we have known that our customers who use the "new" imms admin codes tend to get paid better for them. We figure, just as Dr. Bradley stated at the PCC-sponsored Coding event in NYC recently, that many of the MCOs simply entered the new codes with the new values but didn't update the original codes with the new values.
Wait - unless you know exactly what I'm talking about, that won't make sense. In 2005, CMS introduced the new vaccine admin codes - 90465/90466 (there are others, but these are the doozies). At the same time, they more-or-less doubled the RVU value of all the standard admin codes. We're talking about going from <$10 to >$20. It's a big deal and PCC has many customers getting the new, higher rates. Plus, it's proper coding.
So, even though we still meet and work with practices who don't yet use the new codes - no joke - we have plenty of information that indicates that using the new codes pays off.
Recently, the AAP asked us to look into this issue (and the "-25 modifier" issue, the results of which will follow). Here is some data you simply will not see anywhere else. Sure, some folks have it, but no one else will share. We will, because this is important. So, for 2006, here's what PCC clients did:
There you have it - the average reimbursement for PCC's customers across the country for a 90465 is 62% of Medicare vs. 50% for the 90471. Or, on average, $3 a pop. If you're not using the new codes - and setting your prices properly - then you are losing money. Lots of it.
Oh, yes - I am ignoring that "62% of Medicare" bit. It makes my stomach turn.
I picked up this tidbit from a message forwarded to PedTalk (thanks, Dr. Gewanter). Family Practice Magazine and the associated AAFP (from whom the AAP is finally starting to learn!) "...decided last year to conduct a Consumer Reports-style survey of physicians' experiences with third-party payers."
The results are hardly surprising. OK, I was surprised that United wasn't the worst payor ranked. Rather than summarize the piece, just go read it here. You can get a copy of the report card here. The quotes from Dr. Edward L. Langston, the chairman-elect of the AMA's board of trustees and an AAFP member, are priceless. I'm no great fan of the AMA, but he's got it right here.
• "Many health insurer contracts are essentially 'contracts of adhesion' ... submitted to the weaker party on a take-it-or-leave-it basis and do not provide for negotiation." In many cases, these contracts contain objectionable provisions, such as "all products" clauses and "most favored payer" clauses, and allow the health insurer to change unilaterally any term of the contract.
• "Many health insurer contracts make material terms, including payment, wholly illusory. They often refer to a 'fee schedule' that can be revised unilaterally by the health insurer, and do not even provide such a schedule with the contract."
• "Despite the improper restrictions and potential dangers these terms pose, physicians typically have no choice but to accept them. ... Choosing to leave the network often means destroying patient relationships and drastically reducing or losing one's practice. Physicians simply cannot walk away from contracts that constitute a high percentage of their patient base because they cannot readily replace that lost business."
• "Ironically, rather than focus on the health insurance industry, which ... has boasted record profits and increased premiums corresponding to recent waves of consolidation, regulators have focused on physicians, the least consolidated segment of the health insurance industry."
Another scoop for the blog. Pediatric benchmarks regarding the use of -25 modifers.
This is part of the quick examination the AAP asked us to do. Ultimately, they are trying to determine whether improper payment for -25 modified codes should take priority over immunization admin codes or not. Tough call, though I lean toward the latter.
One of the challenges of this examination is that the proper use of -25 modifiers is so limited. We wondered how many practices use the -25 modifiers at all (and at what rate) and the results took some work to determine. Why? Well, we have some customers who actually put a -25 modifier on every single well visit code. Yup, every one. We have others who put it on almost every single sick visit. And some who do both. Any many who do neither.
OK, enough chatter, here is some interesting data you won't read anywhere else. Tell your friends.
I don't know what the "industry" thinks the proper ratio of "separate and identifiable" services should be, but there's one data point.
Doctor-insurer disputes force parents to pay up front for shots
It's the children who feel the sting of vaccinations, but it's their
parents who can get stuck with a sharp bill for shots they thought their
health insurance would cover.
Some pediatricians, faced with a growing number of recommended
immunizations and rising prices, are starting to restrict or refuse to
administer some vaccines unless patients pay in advance - and the prices
can add up to hundreds of dollars.
East Bay Pediatrics Medical Group, for example, which has nine full-time
physicians and offices in Berkeley and Orinda, informed its 1,800 Blue
Shield of California patients that, as of Aug. 1, physicians would not
administer four specific immunizations without payment up front....
"This is a business dispute, but the parents and kids are being squeezed
in the middle of this," said Dr. Myles Abbott, a pediatrician with the
The piece goes on in some detail (and, whatever you do, don't read the comments from readers), but Dr. Oken was able to provide additional insight on the SOAPM list:
Two items that were incorrectly mentioned in the article : 1. They are not offering to pay 100 % AWP (in fact they want to reimburse Prevnar at below our acquisition cost). 2. They are not the "highest reimbursing health plan in California."
I agree with the practice that it is sad that it has to come to this. But, ultimately, we (the consumers of health insurance) need to play our parts. It's going to get worse before it gets better - we're going to see more of these fights, no question.