Surgery Center of Oklahoma Blog

August 7, 2011

Second Opinions

Filed under: Uncategorized — surgerycenterok @ 4:11 pm

The old joke is, “Mr. Williams, I think you have a problem with your gallbladder.”  ”Doc, could I get a second opinion?”  ”Why, yes,” says the doctor.  ”It might be your kidney.”

The son of a friend of mine suffered a broken bone recently.  I asked who was taking care of him and the answer was one of the truly outstanding orthopedists that works at our facility.  This very experienced and ethical doctor knew that surgery was not indicated and that this young man would heal without any surgical intervention.

I had a few thoughts when I heard this.  My first thought was that when I heard who was taking care of this young man, I relaxed.  There was no doubt in my mind that the right diagnosis was made and that the right treatment will be forthcoming….no doubt….none.  No second opinion needed.  Get it?  One of those guys that always gets stuff like this right. Then I realized that the number of world class surgeons that Dr.’s Lantier and I are surrounded by at the Surgery Center of Oklahoma is impressive.  Our facility is loaded with guys like this.  Surgeons who get it right the first time.  Surgeons who fix other surgeons’ mistakes.  Surgeons who find and diagnose problems every day that many others would miss.  Surgeons who regularly make diagnoses that don’t involve surgery.  Surgeons who are really great people and have been kind and generous with the staff at our facility.

Then this thought:  many of these guys would like to be busier.  Yet, insurance plans prefer many times to send patients to hospitals where none of these great doctors will work.  So some less- able surgeon works on folks that would be better served by great surgeons who would actually like more business.  This cartelization of care has interfered with the discipline of the free market and channeled  patients where they were harmed and kept them from the best qualified physicians in many instances.

As a patient you should keep this in mind when your insurance plan financially punishes you for “going out of network.”

G. Keith Smith, M.D.

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Medicare Fraud

Filed under: Medicare — surgerycenterok @ 3:39 pm

If I didn’t know better I’d say that someone from our local newspaper is reading this blog.  In the Sunday paper there was one article on Medicare Fraud and another on un-needed scooters for the elderly!  In the last blog on private contracting, I listed “risk” as one of the reasons that many physicians will no longer see Medicare patients.  In today’s newspaper, a U.S. attorney for the western district of Oklahoma was urging seniors to recognize and report Medicare fraud and abuse.  Sounds good so far, huh?  Half way through the article, seniors are told that if something doesn’t make sense on their bill or statement they should contact the Medicare fraud hot line.  Starting to get the picture?  Are you imagining thousands of confused elderly people calling this hotline because something doesn’t make sense to them?  Do medical bills make sense to anyone?

Now put yourselves in the shoes of the physician (perhaps a neurologist or an internist specializing in geriatrics).  They have lots of patients that are confused on a good day.  They are being encouraged to call the Medicare fraud hot line.  The storm-troopers arrive at the physician’s office looking for “fraud and abuse.”  They will find it.  A simple mistake on one out of tens of thousands of forms will be found.  This will be determined to be fraud.  Why?  Because that is what the thugs from Medicare are hired to do….they are just doing their job, you know.  The physician can fight this in court (and face certain bankruptcy trying to win this case against the leviathan) or he/she can surrender and pay the fines/penalties and settle up with those in charge of this extortion/shake down/stick up…whatever you want to call it.

When you read that Medicare fraud is on the rise, it is because Medicare and our wonderful public servants in the Dept. of Justice say it is on the rise, not because it is, necessarily.  ”Physicians surrendering to bogus charges of fraud rather than face bankruptcy is on the rise,” is actually more accurate.  Is there fraud in Medicare?  Of course there is.  There is fraud in all types of insurance.  This is the nature of having third parties pay bills, rather than those receiving the product or service pay the bills.  How about this?  ”Dr., I’m writing my check for today’s visit and you have charged me for a urine check that wasn’t done and I don’t want to pay for what wasn’t done.”  Isn’t that where the accountability should be?  Dr. says,” I’m sorry.  I checked that box and didn’t mean to.”  Or alternatively, the physician says,”Nurse!  Why didn’t you get a urine sample like I asked you to?”  Could this be interpreted by the Medicare police as fraud?  Yes it could.  Yes it has.  Physicians are in jail for this kind of stuff.

“Doctor?  Can’t you do a full blood workup on me?  I know my last one was a month ago but I sure would like to have that re-checked.  It’s not going to cost me anything ’cause Medicare will pay for it.  Just go ahead.”  Is this fraud on the patient’s part?  ”I see other folks riding around on those scooters at the grocery store and I can’t afford one but my buddy who has the same Winnebago I do said that if you will just write me a prescription then Medicare will give me one.”  Only when patients are responsible for payment of their care will the incidence of fraud and abuse on both ends decrease.

How about this for fraud?  All of the money that people have paid into social security and Medicare over the years is gone.  Now that’s fraud and abuse.  Hospitals increase prices for those of us who are paying to “cover” those who can’t pay……all the while knowing that they will be paid later for this “free” care….now that’s fraud.

I predict that fewer and fewer physicians will see Medicare patients as demented old folks light up this hotline with items that “just don’t make sense” on their bills/statements.  Most of the elderly will never understand that recruited as brownshirts, they may completely lose access to the physician that has taken care of them.

G. Keith Smith, M.D.

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August 5, 2011

Private Contracting

Filed under: Medicare — surgerycenterok @ 3:59 am

Many physicians are no longer accepting Medicare.  Some  are continuing to see Medicare-covered patients but with the understanding that Medicare will not be involved in the payment of care rendered by the physician.  Why would a doctor do this?

Risk:  if a physician makes a mistake on a Medicare claim (no matter how innocent) he/she is eligible for a stay in a federal prison and bankrupting fines.  The Medicare storm-troopers descend on his/her practice and rifle through all of the physician’s files and find all of the “mistakes” they could possibly need to put the physician in jail or bankruptcy.

Payment:  payments to physicians for Medicare patients are often times below the costs incurred to see Medicare patients.  Legal caps are placed on these payments and contrary to what many Medicare patients think, physicians can’t just bill them whatever they want.  Secondary insurance is therefore a scam, as physicians can’t bill beyond the limits imposed by Medicare in the first place.

Oath:  Some physicians (fewer and fewer, sadly) took their Hippocratic oath seriously.  As physicians we are obligated to do what we think is in the best interest of the patient…..PERIOD.  If a third party has a restrictive formulary or otherwise places obstacles preventing what is best for the patient, that represents an impossible dilemma for the physician and one many are increasingly unwilling to face.

Philosophy:  Some physicians believe that Medicare money is stolen property.  I, for instance, have no right to the income of my neighbor for an anesthetic that I provided to some guy for his knee replacement that my neighbor doesn’t even know.  Many times physicians represent themselves as fiscal conservatives, wanting small government, but at the same time will lobby Congress’s gang of 535 for more money from Medicare!

Dedication:  some physicians are dedicated to their patients….hard to believe, huh?  This is why many are willing to turn to a method of payment known as “private contracting.”  Medicare patients typically sign a waiver in which they acknowledge that no Medicare claim will be filed by either them or the physician and that payment will be made directly to the physician.

Private contracting will, I believe, become an increasingly common practice as Medicare’s bankruptcy becomes more apparent.  Physician payments will be slashed again and again and the delays in payment will increase over time.  Fewer and fewer services will be covered and in order for a Medicare patient to be seen in a timely manner (wow!…sounding kind of like the mess north of the border, huh?!) they will have to pay the physician directly or even go to a foreign country if this practice is made illegal.

I have mixed feelings about private contracting.  I have done this to some degree, but see it as a way to prop up “the system” for a longer time than it would otherwise stand on its own.  People that are sick or hurt need care, though.  But the entitlement mentality among the Medicare population is very distressing.  I don’t believe that any real changes to Medicare or abolishing this Ponzi scheme are likely until widespread shortages of physician services to this group of people emerge.  Only the distress and the complaints of the Medicare population will result in the dissolution of this wealth transfer scheme.

I believe that this is coming and that there is hope for the wonders of the free market in medicine for the elderly once again.  Ironically it will be the bankruptcy of Medicare that is the salvation of the health of the individuals that are held captive by this “program.”

G. Keith Smith, M.D.

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August 2, 2011

Out of Network Math

Filed under: Uncategorized — surgerycenterok @ 3:16 am

You need your knee fixed.  Your orthopedist wants you to go to a facility that’s out of your network.  You are miffed because this is going to cost you alot of money.  Or is it?

Your benefits are 80%/20% in network and 60%/40% out of network.  What does this gobbledegook mean?  It means that your out of pocket responsibility is 20% if you go to an in-network facility and it means that your out of pocket responsibility is 40% if you go out-of-network.  OK…SO?  If the charge or the allowable billed amount of the in-network facility is $12,000, your responsibility is 20% of that, or $2,400.  If the charge or allowable amount of the out-of-network facility is $3740 (our online price) your responsibility (40%) is $1496.  What?  You mean that your out-of-pocket expense for a surgical experience at the Surgery Center of Oklahoma is less than that at a big (not-for-profit) hospital?  How can this be?

Why are the insurance companies determined to direct you (scare you) to a facility where you will be out of pocket more money?  What could possibly motivate them to do this?

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Medical Home Exchange

Filed under: Uncategorized — surgerycenterok @ 2:39 am

You live in Dallas.  You go to see your trusted family doctor.  You need your gallbladder out.  He goes online.  He has paid for a service called iRefer.  This gives him access to online ratings of facilities and their quality of care.  He can even search for price where it’s available.  He tells you that you can stay in Dallas and pay $28,000 for your gallbladder removal.  Or you can go to Oklahoma City and have a “5 diamond rated” surgeon at  a “5 diamond rated facility” remove your gallbladder  for $5655.”

What would you do?  What do you think the company you work for (if they are self-insured) wants you to do?  What if your company told you that your deductible would be waived and you would have no co-pay if you went to OKC?

Check out Medical Home Exchange. This may be the new paradigm of health care in the old USA.  Unless the government outlaws this innovation.

G. Keith Smith, M.D.

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Tax Code

Filed under: Uncategorized — surgerycenterok @ 2:27 am

Why is health insurance tax deductible for businesses and not for individuals?  Could this possibly be a benefit to big insurance companies?

Put yourself in the shoes of the insurance company.  Wouldn’t you rather deal with a company’s human resources staff than to deal with each and every one of the employees of a 1000 employee company?  Wouldn’t you rather sell one policy that covers “1000 lives”  than to issue 1000 policies?

Now, consider Obamacare.  Five, maybe six regions of the country.  Each covered by one of the giant insurance companies.  Done.  No competition.  No need to provide customized insurance coverage to individuals.

Wonder why the insurance industry supported this fiasco?

G. Keith Smith, M.D.

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Scope of Practice

Filed under: Uncategorized — surgerycenterok @ 2:20 am

Years ago I was at a dinner for some Oklahoma State legislators.  I was new to the political scene.  The fellow that set up the dinner was aware of my libertarian philosophy and sat me next to the most conservative legislator in the State senate.  He told the legislator, “ok…here is someone that makes you look liberal!”  The senator accepted the challenge.  He said, “where do you stand on ‘scope of practice?’”

Without hesitating, I said, “Let God sort them out.”

He turned to the dinner host that arranged the seating and said,”O.K.  You are right.  He is a libertarian.”

I have always marveled at the anesthesiologists and ophthalmologists that fight with nurse anesthetists and optometrists.  Nurse anesthetists want autonomy.  The anesthesiologists don’t want them to have it….they want to supervise the nurses.  Yet, in rural Oklahoma, nurse anesthetists are all that’s available when an emergency C-section is needed…or an emergency appendectomy.  Maybe they only need this “all-knowing” supervision when they are in the “big city.”

Optometrists want to do laser surgery.  Ophthalmologists don’t want them to do this.  Why?  Because patients are in jeopardy?  Or because they want protection from this group?

Money flows into the state capitol from both sides.  Statements are made.  Facts and figures are produced.  Statistics and studies are cited.  Year after year, the same result.  Nothing.  Why?  What kind of idiot would a legislator have to be to solve this?  Once it is solved, the game (money) is over.

Why not let the market work?  As anesthesiologists, our training should provide us with skills that place us in a position to compete with nurses that have not attended medical school and therefore lack the rigor of our training.  As ophthalmologists, the training necessary to complete this difficult path dwarfs the path taken by their optometry counterparts.  So why fear competition?  Why ask the legislator to get involved?  Why not embrace the discipline the free market provides for those unable to complete the task/service advertised on their shingle?

I know anesthesiologists that I would not let touch me.  I know nurse anesthetists that I would feel completely comfortable anesthetizing me.  Why not leave the government out of it.

I stand by my original statement:  ”..let God sort them out.”

G. Keith Smith, M.D.

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Cowardice or Evil

Filed under: Uncategorized — surgerycenterok @ 1:29 am

Over the years I think I have had trouble distinguishing between cowardice and evil.  I am now realizing that awful and evil results are often the result of cowardice, not evil intentions, as only the rare individual has evil intentions (most politicians, for instance).  Cowards are everywhere.  They are in government and in the private sector.  They are in industry, energy, medicine and law.  Many laws are the result of cowards trying to “buy” protection from the government from their competitors, for instance.

The average physician is no match for the savy hospital administrator or insurance executive.  These corporate types are risk takers by nature and often times are taking risks with corporate money (the so-called moral hazard scenario).  I have faulted physicians that signed up as hospital employees and have failed in the past to recognize that this compromise is a result of fear, not some failure of character.  I believe that the same is true for those signing up for insurance contracts such as HMO’s and other rationing  instruments that are horrible arrangements for the physician and the patient.  This enrollment is an act of fear or cowardice even though the results are regularly awful and evil.

Some physicians ask the legislator to protect them from someone on their turf.  This, too, is an act of fear.  Anesthesiologists are notorious for their attacks on nurse anesthetists.  Ophthalmologists are always after the optometrists.  Otologists are after the audiologists.  I could go on and on.  The argument is always the same.  ”We, the annointed ones, are here to protect the public from those with inadequate training from certain harm/death/you name it.”  This is cowardice, pure and simple.  If hospitals need “protection” or “certificates of need” to keep the specialty hospitals from competing with them, they are, quite simply, cowards, not evil actors.  If surgeons are afraid that their referral base will dry up unless they surrender to the big and powerful hospitals, they are cowards, not evil people.  Wimps not devils.

Or does the fearful trait present in so many physicians represent a flaw in their character?  I think it represents a flaw in our training.  This fear serves to make us short-sighted and poor decision and people managers and incapable of dealing with the hospital administrator types.  I throw this blog out there hoping to start a dialogue not so much to be provocative or judgemental.

Let me know what you think.

G. Keith Smith, M.D.

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Filed under: Uncategorized — surgerycenterok @ 1:12 am

A very good friend and colleague asked me today if I knew a place that a relative of his could obtain an ultrasound test for possible gallbladder dysfunction.  This relative had no insurance and was looking for an affordable facility/radiologist.  They had called their local hospital in an Oklahoma City suburb.  The price:  $875.  This, however, did not include the radiologist’s fee.

I gave him a phone number.  Who did I recommend?  Why, a greedy doctor-owned facility, not three blocks from the $875 hospital.  Their price?  Ready?  $187.50.  Including the radiologist’s fee.

Opinions are opinions.  Facts are facts.  The above is only one illustration of the fact that physicians are generally not the problem with the high price of health care.

G. Keith Smith, M.D.

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