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.
Well, sadly, not more reimbursement. That's the problem. More about it.
From the Washington Post, we have another piece similar to last month's NYT article about the problems with immunization reimbursement for private practice pediatricians. It would be hard to overstate the importance of this subject in our world these days. Dr. Lessin is quoted again, so those coming to see him at our Users' Conference should expect more of the same (he's no shrinking violet):
I have to pay for nursing time, supplies, syringes, alcohol pads, dropped doses and time to explain it," Lessin said of the ancillary costs of providing vaccines. "And when insurance companies decide to pay me $122 per dose and take three months to pay, I can't afford to do it. For insurance companies that are paying me $140 or $150 a dose, I'll give it."
I then got a message about Beechstreet's continued lowball reimbursement for some key imms (like ProQuad at $35 or something like that when it costs >$100/dose to purchase...someone correct me if I'm wrong). Given all the other problems with Beechstreet, I often wonder why practices even participate with them.
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.
In 2007, CMS gave values to two important pediatric codes for the first time, the 92551 (hearing test) and the 99173 (vision screen). Sure, the values aren't astronomic, but that extra ~$10 for each test, which are part of a standard well visit, means a lot to a pediatrician.
Then along comes Oxford.
E & M Utilization
Several recent changes to OXP policies related to E & M coding include
bundling the vision screening code 99173 into visit codes. This became
Yeah, we'll just ignore CMS entirely and, retroactively, deny paying for a fundamental preventive care procedure. You know, one that could save the vision or hearing of your child.
Sigh. This is, of course, one of hundreds of these little missives our clients get throughout the year.
How do I even know about this? Because of the lovely work by The Verden Group. Ignore that silly quote on their front page (I wasn't paid a dime, I promise!), it's a very cool service.
It dawned on me that it would be helpful to let people know about valuable pediatric resources. For example, I expect to do a quick review of groups like Physicians' Alliance and Pediatric Federation soon.
I'll start with a self-reference: PCC's Pediatric Practice Management Conference on July 19 in Vermont. We've got Donelle Holle, Drs. Hagan and Lessin, Rosemarie Nelson, and Carol Rutenberg. Big names, great topics. Plus, Vermont is beautiful in the summer time. Can't be beat.
Six years ago his mother abandoned him and his younger sister in the woods of Ghana because they were both blind. They were only 11 and 8 years old.
For three months they drank rain water and ate food from a nearby garden until a passerby brought them to an orphanage.
Reading about these kids helps me put my complaints into perspective. Thank you to the folks from OCI for doing the work for us.
A customer called me yesterday to ask, "[Evil Empire HMO] has finally come to the table and is offering me 100% of Medicare on my E&Ms...should I take it?"
Normally, I'd say, "100%? That's a joke." But this client was calling from a part of the country where pediatric practices average 65-75% of Medicare. I know of at least three groups (of 5-20 practices each) within 70 miles of of this practice who are trying to merge for the stated purpose of negotiation. So, here we have a small practice getting one of the worst HMOs to the table on their own. I figured I'd better check to see what the deal would be worth.
We spent a few minutes in Partner. If just their 99211s through 99215s are raised to 100% of Medicare, the practice will bring in an extra...$175,000. Every year. For for just this one payor.
We quickly agreed to ask for 100% of all codes (you always have to ask), but take 100% for a one-year contract. And ask for 105% or 110% next year.
Next time you think you need to be big to negotiate, remember this, Example #754.
It's difficult to narrow down the math stories to just one, there are so many, but here's this week's for a start. From one of the only payors who behaves worse than United/Oxford, a letter to a client of ours in the northeast:
The best offer the [we] will provide to your practice is 100% of
2007 Medicare for E&M codes only for a two year term. If you choose to
accept the range of CPT codes we discussed within E&M, [we]
will offer 105% of 2007 Medicare for a two year term.
As we discussed, there will be no enhancements offered for lab services or
immunizations/vaccines. Although we understand your dissatisfaction with
the current reimbursement structure, our position on this has not changed
regarding the negotiation.
Please advise as to how you would like to proceed.
I know how I would have liked them to proceed, but this practice is more reasonable.
Still, the math is out on the table. Which would be better for your practice - 100% of all E&M codes (99201-15 and 99381-95) OR 105% of just the established codes (99211-5, 99391-5) with all other codes at your existing rates?
Here's today;'s hint: do the math. Whenever an insco gives you a choice, there's one that benefits you more than the others. My gut instinct - and the practice's - was that 100% across all the E&Ms was the way to go. But I took the time, and did the math. Which the insurance companies never expect you to do. Otherwise, why are they even giving you a choice? The results?
The difference, based on the last 12 months of business, between what they are paid now and the deal I would have taken without looking: $180,000. With the second deal? $205,000. That's a $25,000 difference which, in pediatrics, is real money. They are taking the second deal. Looks like the insco had a $200K limit they were trying to stay under and, by giving you a choice, increased their odds of beating their own self-imposed limit.
Note that this is a small/medium sized pediatric group who just negotiated a +$200K deal on its own with a significant payor. Awake, sleeping giants indeed.
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.