I want to earn $910 per hour

It boggles the mind that some people think the cost of healthcare will go down if all doctors become hospital employees.  When a private practice doctor can make a profit by seeing patients for $200, but the fee for the exact same 25 minute appointment becomes $455 when the doctor is employed by a hospital, something is dreadfully wrong.

How can charging more than double be construed as reducing costs?

To me, it seems that patients could put an end to such nonsense by refusing to see a doctor employed by any hospital using such tactics.  Unfortunately, it doesn’t work that way.  Since the insurance reform law passed, it’s getting harder and harder to find doctors in private practice.

For my daughter, it’s impossible.  According to the ACR, there are only five practicing pediatric rheumatologists in my state.  All of them are at Children’s.  If it were me, I’d look for a different doctor – one not affiliated with a hospital extorting facilities fees.  I can’t take my daughter elsewhere, though; there is nowhere else.  We’re stuck.

We recently discovered something that sheds a little light on the situation.  The hospital is requiring doctors to do lots more computer work.  An oddly reasonable administrative ruling has lightened doctors’ patient load to give them time to do that paper computer work.  The problem that the hospital ran into is that if doctors see fewer patients, they’ll earn less money and that puts a huge crimp in the cash flow.  Now I understand the reasoning behind the facilities fee.  Instead of seeing two patients to earn $400, they’ll just see one patient and charge $455.  Half the work, but even more income.

There’s a flaw in that solution.  Tacking on a facilities fee does not mean that the hospital will get more money.  It means that people like me, who would never have dreamed of asking for financial assistance in the past, are now doing it.

Welcome to unintended consequences.

Highway Robbery

Charging a “facility fee” in addition to physician fees for a doctor’s appointment is immoral.  It is a barbaric method of gouging extra money out of people who are sick and desperately in need of a physician.

Imagine if the only physicians available to treat your condition worked 65 miles away at the outpatient clinic associated with a specialty hospital, and you received a hold-up letter:

Starting Oct. 1, we will bill a facility charge for hospital-based clinic visits…

A facility charge includes hospital expenses for a clinic visit that are separate from the cost of the medical provider.  You will continue to receive a separate charge from your medical provider for their (sic) services.  The facility charge includes costs for running the “facility” like supplies, equipment, exam rooms and other hospital staff…

Supplies, equipment, exam rooms, and support staff are simply part of the cost of providing medical care.  The high cost of doctor’s appointments is often justified because that money pays more than the doctor’s salary; it pays the support staff, the rent or mortgage, and the other costs associated with running a business.  Those costs are similar everywhere.  All businesses have overhead costs.  Those expenses don’t justify extra fees, and it is ludicrous for hospitals to think they’re special in this regard.

In an attempt to justify this travesty, the letter goes on:

All our other departments charge a facilities fee, so now the outpatient clinic will be billed the same way.

This is a standard practice for most other hospital-based clinics.

Due to recent funding cuts, we have to find somewhere else to get the money.

The fact that hospital facility fees are charged for hospital services, in no way implies that hospital facility fees are appropriate for outpatient services.

“Everyone else is doing it” isn’t an acceptable excuse when kids say it, and it’s not acceptable here.  First, because everyone else isn’t doing it.  Second, because it doesn’t matter what everyone else is doing (if everyone else was jumping off a bridge, would you do it?).

I am outraged to think that this hospital thinks they can charge every patient seen in an outpatient clinic an extra $255 per appointment.


Are the Accountable Care Organizations defined in the health insurance reform law something that RA patients need to be concerned with?  On one hand, ACO’s deal with Medicare, so don’t directly affect people who aren’t on Medicare.  On the other hand, anything my doctors spend their time and energy on has the potential to affect the care everyone gets, so we all have a stake in the game.  Any policy on healthcare has the potential to spread to other areas, affecting us all.

Regardless of whether you were for or against the health care reform legislation, the creation of Accountable Care Organizations is one portion of the new law that is particularly puzzling.  Everything I’ve read about it makes me say, “That’s not new.  It sounds like an HMO.”

Instead of acting independently, doctors and hospitals are to form partnerships to oversee patient care, and will spend thousands (millions?) of dollars to jump through all the legal hoops of getting the ACO set up.  New employees will need to be hired to deal with the added workload.  Computerized medical records are a must for Accountable Care Organizations, so every member of the ACO will be required to spend money on EMRs that will talk to one another.  That’s a pretty costly experiment!

In most businesses, people make investments when spending that money means they’ll be able to earn even more money.  Not here.  The goal of ACO’s is to reduce the cost of medical care.  Reducing the cost of medical care means that the hospital/doctor/testing facility will earn less money.  From a financial standpoint, I can’t for the life of me figure out why medical providers would spend massive amounts of money for the privilege of taking a pay cut.

What about on the patient side of the equation?  People who want an HMO have Medicare Advantage; people who don’t want an HMO go with the fee-for-service option.  Now ACOs will take those fee-for-service patients and force them into the renamed HMOs.  Patients may also find that they’ll be seeing less of their doctor, since people seem to believe that in ACO’s doctors will be required to act as administrators overseeing mid-level providers who do the actual patient-care.

Another problem is that patients with health challenges might find it difficult to get a doctor who will care for them.  There are goals – for instance, diabetics should keep their bloodwork in a certain range, people with hypertension also have a target range in which their blood pressure should fall.  One of the reasons that ACOs are required to have an EMR is so that they can send reports to the government on how these patients are doing.   If labs and blood pressure fall within the goals, doctors get a bonus.  If patients aren’t doing as well as the national standards recommend, then no bonus.  Some pay for performance models are even reported to dock physician’s pay when patients don’t meet goals.

Notice that doctors lose pay when patients don’t do as well as desired.  How stupid is that?  Doctors can only diagnose and suggest a treatment plan.  They don’t follow patients home and supervise the exercise regime.  They don’t hand patients their medicines three times a day and watch to make sure the pills are swallowed.  They don’t police their patient’s dinner menus.  It’s the patient’s responsibility to carry out the treatment plan.  It would be much fairer if coverage were restructured so that patients had 100% coverage if all treatment goals are met, but only 80% if they’re only close to the treatment goals, and maybe only 50% coverage if it’s obvious that the patient is making no attempt to live a healthy lifestyle.  Pay doctors fairly for their work, and give the financial rewards/penalties to the patients based on how successfully they implement their treatment plan.

Under this ACO system, doctors will eventually drop patients who aren’t doing well.  Why take $25 to care for someone who isn’t meeting the treatment goals and takes lots of care (time), when it’s possible to be paid $50 for people who don’t need as much care and don’t need to be seen as often?  It’s not that the sicker people will cost less to care for, it’s that they won’t be able to get care at all.

That really scares me.  When doctors can be better compensated for cherry-picking healthy people, instead of taking care of those who truly need medical help, we should all be concerned.