patrick.net

curious2 says

Why not just take a photo with a ruler next to it and check it again in a few weeks to see if it's changed?

I was going to say that the code would also depend upon the size of the mole. The bigger the mole, the more expensive it is.

Of course the doctors don't want you to know how much the office visit is going to be in advance, since if you knew, you would shop around.

thomas.wong1986 says

Dr. Kirk A. Churukian (http://www.drchurukian.com)
one mole removal goes for $250

Nice that you can get a quote, but the price is still outrageous.

burritos says

I know for a fact that Kaiser's CEO/chief is an MD, who make maybe 25-50% more than your fellow MD, but not like the Health Net and Aetna CEO's who make 10's of millions of dollars a year which are dollars that could go to patient care

How much does Mr. Halvorson make? just curious

burritos says

And I take umbrage of the characterization that they are there to deny care

The physicians aren't there to deny care - the case managers & administrative staff take care of that. Everything must be in-plan and pre-authorized. This system isn't perfect, because of the inability to receive a second opinion from an out-of-plan physician who may be an expert in the field. Please don't get your panties in a knot over this - IMHO when you restrict the ability to access providers you often restrict the chances for a positive outcome. Not always, but it happens.

burritos says

If they want disjointed care where the specialists only want to take care of them solely based on the fact that they have "PPO" insurance, then have at it, but believing that it's superior care without limits is a fallacy.

I didn't say there aren't limits - but HMO's only work in a specific area and for the above mentioned reasons they're not always the best option. An example would be Mesquite Nevada (pop 10,000), where an HMO in Vegas came in and signed a shitload of seniors (Medicare HMO) onto their plan in 2000. There was one local physician and no nursing home/rehab provider; at that time there was also no hospital. So people had to go to Las Vegas - 1-1/2 hours away - to be treated, receive rehab, etc even though there was a regional hospital half an hour away. Things aren't much better now, they have a teeny hospital but the majority of treatment must be provided in Las Vegas.

In this example, the HMO limits the ability for patients to be seen and treated by a nearby provider. HMO's only work in urban areas, and limit the patient's right to choose providers.

curious2 says

(changing the medical record) must be a big temptation, because it happens, but if exposed it destroys the doctor's credibility.

It's hard to falsify the medical record and get away with it - everyone's charting has to support everyone else's. If a doc changes something, it doesn't jive with the nurses, emt, social worker (if there is one), etc. Most docs I've met are dedicated and caring, and I doubt they'd falsify the records.

Burritos, you're on the medical side. I'm on the hospital case management side. I've seen my share of denials - and it ain't pretty. Let's agree to disagree that Kaiser is awesome - but we both agree that most physicians and medical providers are cool.

bdrasin says

You know Patrick, you've said you don't like Kaiser Permanente in the past but one of the big advantages is that its a single organization. Meaning there's no back-and-forth between the doctor, the hospital/clinic and the insurance co.

Can they tell you costs in advance?

I'm sure they can. Not sure if they will :-(

drtor says

Not designed to deny benefits, but yes to reasonably limit unnecessary procedures and evaluations within standards of medical care.

Yes. And of course also countries with single payer systems have to put in these kinds of limits. Do you really think that in Canada, Sweden or Cuba people get any kind of procedure or test they can imagine? No, doctors follow standards set by administrators that consider both costs and benefits.

This is just an anecdote, but my father dislocated his shoulder while working in Sweden. It was the weekend and a nurse decided (much to his displeasure) that it could wait until Monday and sent him home with some pain killers. On Monday, the doctor told him that he would recover from the injury without medical intervention beyond pain medication and some physical therapy. Again, he was pissed and wanted to know what they could do to fix him right away but it was to no avail. Of course the doctor was correct and he gradually got better over the course of six months.

I don't know for sure, but I suspect in the US the case wouldn't have been discharged so cheaply; there would have been more incentive for tests/treatment that wouldn't have really made a difference (at least once they found out he had insurance).

Anyway, this is kind of getting off - topic...

elliemae says

How much does Mr. Halvorson make? just curious

George makes 8+ million per year in direct compensation, and has numerous pensions on top of that. Kaiser is now trying to get rid of the single pension that its (non MD) workers have.

Zlxr says

What I was trying to say is that there are thousands of procedure codes and the Doctors certainly don't know them all - and often don't know the ones that are the most helpful for their billing. It could even take a few more years of studying just to learn how to get paid - and that's after they learn how to treat us.

The problem is that codes can change annually, not the actual number of codes. However a biller/coder would be able to stay on top of that for the salary you pay for a good medical assistant.
With ICD-10 coding system coming out, there's going to be a lot of headaches for the practices that aren't ready for it. I can see major problems there.

elliemae says

And I take umbrage of the characterization that they are there to deny care

Having worked for Kaiser I can tell you that the medical foundation certainly imposes limits on how much your MD is allowed to treat you, they are just very sly about it.

One example- they keep records of how many CT's/MRI's every doctor orders. You do not want to be number one on that list at the end of the month unless you like having "talks" with your chief.

elliemae says

How much does Mr. Halvorson make? just curious

The former CEO of Southern California Kaiser Permanente was Jeffrey Weisz. He was a 20+ oncologist before he went from Chief of Woodland Hills to Head of Kaiser. The word of mouth from Kaiser docs was his base pay was 350k(not knocking it out of the ball park for oncologists)+25% as top administer. Word is that his last year he was given a out the door bonus for meeting his stated goals(number one in colon ca screening and mammographies for southern california medical groups), which was about 100k. It's a lot of money but easily 2 logs lower than your typical ceo with a golden parachute that did nothing but increase stock price. He was quickly head hunted by the Northwest Kaiser group to improve their situation. Is Kaiser awesome? No, nothing about medicine is awesome. But as someone who serves a lot PPO insurance, Kaiser I think is much better IMO.

elliemae says

I didn't say there aren't limits - but HMO's only work in a specific area and for the above mentioned reasons they're not always the best option. An example would be Mesquite Nevada (pop 10,000), where an HMO in Vegas came in and signed a shitload of seniors (Medicare HMO) onto their plan in 2000. There was one local physician and no nursing home/rehab provider; at that time there was also no hospital. So people had to go to Las Vegas - 1-1/2 hours away - to be treated, receive rehab, etc even though there was a regional hospital half an hour away. Things aren't much better now, they have a teeny hospital but the majority of treatment must be provided in Las Vegas.

How funny. I'm in Zion this week. Were these patients mandated to join the LV group or could they have joined a closer group? I'm guessing they could have but would have had to pay more to join that group. There are a lot a timbuktu's all over the country. Are insurances obligated provide state of the art facilities for everyone everywhere? You know there's not enough money even in China to do this.

No, there's only the LV groups they could join because the insurance doesn't reach across state lines.

Insurance plans are required to have providers, but not necessarily in your area. So, if there's no contracted pharmacy near your home it's not their problem. Same with hospitals, or MD's, etc. To rehab, patients in Mesquite have to go to Las Vegas. Family can't visit, transporation home is a problem if they don't have cars (many don't, Mesquite is quite depressed) and going to the doc is an all-day ordeal. The insurance marketers who are paid $500 each pt to sign on service and a bonus if they stay on after 5 years certainly don't tell them this - and signing off service is almost as hard as getting girls gone wild to stop sucking $$$ out of your bank account after the free trial.

My favorite (easy) Zion hike is the overlook trail right after the tunnel - it's a mile hike and absolutely beautiful. When I was little, we used to run through the tunnel holding a stick hitting the walls to orient us because it was so dark. When a car came we'd jump between the supports - it's called "tunnel running." It sure freaked people out when they thought they'd seen ghosts in the tunnel. Unfortunately they closed the tunnel to that sort of thing. It was fun.

Since you're here, have you been to Snow Canyon (up hwy 18 in St. George)? It's gorgeous - at least drive through it on your way back to civilization.

RedStar says

Having worked for Kaiser I can tell you that the medical foundation certainly imposes limits on how much your MD is allowed to treat you, they are just very sly about it.

It's burritos who takes umbrage... I worked taking denials to patients.

By the way, burritos, since you're here and obviously a doctor, can I get a consult? It hurts when I move my arm...

I don't work for Kaiser, but have many friends and family who are physicians who do. These physicians are getting killed.
I'm curious what you mean here? I've told this story before, but I know someone who enjoys working at Kaiser much more than her previous hospital gig. If she sends someone to a specialist, a lot of time the specialist comes to her office to see the patient. She gets to see the specialist in action and broadens her general medical knowledge. BTW, it's nice to have someone else here defending Kaiser as I usually take a lot of arrows. Elliemae, I'm enjoying the back and forth; you certainly have some good points regarding care outside of urban areas.

My last doctors office visit was $290, just to write 2 prescriptions. I cancelled the follow up visit. I felt ripped off.

elliemae says

My favorite (easy) Zion hike is the overlook trail right after the tunnel - it's a mile hike and absolutely beautiful. When I was little, we used to run through the tunnel holding a stick hitting the walls to orient us because it was so dark. When a car came we'd jump between the supports - it's called "tunnel running." It sure freaked people out when they thought they'd seen ghosts in the tunnel. Unfortunately they closed the tunnel to that sort of thing. It was fun.

Did overlook last night after we dumped our kids with grandparents. Quickie but goodie. Just did riverside walk. Always pleasant especially when your 5 year old tells you he has to take a crap midway through the hike. Now it's nap time for my 2 year old and the lucky grandparent get to take a shot at Angel's Landing while I get to debate medical benefits on a real estate board.

elliemae says

By the way, burritos, since you're here and obviously a doctor, can I get a consult? It hurts when I move my arm...

No trauma right? I'll usually shoot an xray at the site of the pain which in my 10 year career has never shown anything significant. Then so long as there's no side effects or adverse effects, I'll usually prescribe a tapering course of steroids, a muscle relaxer, and a narcotic if it's a lot of pain. Sometimes I'll prescribe a BCKL(baclofen, cyclobenzaprine/ketoprofen/lidocaine) topical gel if people aren't into pill popping. Then, I'll offer PT, if that is the patient's thing. Then I'll give the patient an ortho eval for local injection if not better in 10-14 days.

burritos says

elliemae says

By the way, burritos, since you're here and obviously a doctor, can I get a consult? It hurts when I move my arm...

No trauma right? I'll usually shoot an xray at the site of the pain which in my 10 year career has never shown anything significant. Then so long as there's no side effects or adverse effects, I'll usually prescribe a tapering course of steroids, a muscle relaxer, and a narcotic if it's a lot of pain. Sometimes I'll prescribe a BCKL(baclofen, cyclobenzaprine/ketoprofen/lidocaine) topical gel if people aren't into pill popping. Then, I'll offer PT, if that is the patient's thing. Then I'll give the patient an ortho eval for local injection if not better in 10-14 days.

Yes, but can you tell me in advance what it will cost?

There's a simple fix to this. A law that the state will mandate a price if one isn't given beforehand.

elliemae says

By the way, burritos, since you're here and obviously a doctor, can I get a consult? It hurts when I move my arm...

Ahhhhhh, you were supposed to say, "don't move your arm."

Unfortunately, it's RA that chose to settle in the site of some pretty hefty horse-bucking traumas. Prednisone for flares, drugs for maintenence. Enjoy Zion.

bdrasin says

Yes, but can you tell me in advance what it will cost?

$90 for new patients. $80 for repeat. $100 for the xray. I give the patient the option if they want it. I usually tell them it's highly unlikely that the xray will show anything, but if THEY want me to be complete we'll be happy to irradiate them unnecessarily. When I put it that way and I do put it that way, surprisingly 30-40% who pay cash still want the xray. So imagine in the insurance world, why would any patient turn down anything?

elliemae says

elliemae says

By the way, burritos, since you're here and obviously a doctor, can I get a consult? It hurts when I move my arm...

Ahhhhhh, you were supposed to say, "don't move your arm."

Unfortunately, it's RA that chose to settle in the site of some pretty hefty horse-bucking traumas. Prednisone for flares, drugs for maintenence. Enjoy Zion.

Eschew Obfuscation

Zion was awesome. On to Bryce.

This view is enough to make any sick person well - Snow Canyon (which I bragged about already). 10 miles Northwest of St. George, Utah on Route 18.

Don't the hard-core Mormons live in that area? Polygamy and all?

Actually I have gotten estimates for dental work. I got the dentists office to submit codes for estimate to the insurance company and a month later I get the estimate in the mail. Not a particularly good way to do it since one can't always wait a month.

burritos says

bdrasin says

Yes, but can you tell me in advance what it will cost?

$90 for new patients. $80 for repeat. $100 for the xray. I give the patient the option if they want it. I usually tell them it's highly unlikely that the xray will show anything, but if THEY want me to be complete we'll be happy to irradiate them unnecessarily. When I put it that way and I do put it that way, surprisingly 30-40% who pay cash still want the xray. So imagine in the insurance world, why would any patient turn down anything?

I was sort of joking, but your response got me thinking...I guess maybe in the same situation a sweedish doctor and probably also a doc at Kaiser Permanente would be explicitly deviating from the "standard of care" (I hope I am using this term correctly) and have to justify the decision. What people want isn't always what they need.

I had a dog with edema (swelling) in his back legs. They gave him lasix to reduce the fluid retention and heart meds to treat the underlying condition. It worked.

Same thing - only with a person... they undergo all sorts of tests and arrive at something definitve, only to be treated with lasix and cardiac meds. It's the threat of being sued, and also the off chance something else could be going on, that causes thousands of dollars worth of tests.

I still have patients who get a common cold and tell me they're going to ask for antibiotics. I tell them they can go to the doctor and get treated, and that they'll be better in about 7 days. But if they don't, they'll be sick for a week.

;)

elliemae says

I had a dog with edema (swelling) in his back legs. They gave him lasix to reduce the fluid retention and heart meds to treat the underlying condition. It worked.

Same thing - only with a person... they undergo all sorts of tests and arrive at something definitve, only to be treated with lasix and cardiac meds. It's the threat of being sued, and also the off chance something else could be going on, that causes thousands of dollars worth of tests.

I still have patients who get a common cold and tell me they're going to ask for antibiotics. I tell them they can go to the doctor and get treated, and that they'll be better in about 7 days. But if they don't, they'll be sick for a week.

;)

Eschew Obfuscation

Swelling in the legs most commonly is caused by dependent edema, which is basically your veins in your leg is getting less efficient. No biggie. But swelling legs can also be caused by early liver failure, heart failure, kidney failure, deep venous thrombosis of your inferior vena cava, pelvic tumor resulting in obstructin of your lymphatics. Personally, I usually just give lasix and skip the tests, but I think most patient would prefer their doctor consider some of the other serious possibilities. For me, usually just roll the dice. After all, it's not my legs and I figure if they don't get better, they'll be back, or in the ER, or worse.

okay, i could have said that he was elderly and his breed typically has cardiac problems. While he was there, they placed a kitten next to him and she stuck her tail in the air... Then they threw a ball and a labrador retriever brought it back.

Having performed a cat scan, and a lab test...

elliemae says

had a dog with edema (swelling) in his back legs. They gave him lasix to reduce the fluid retention and heart meds to treat the underlying condition. It worked.

Same thing - only with a person... they undergo all sorts of tests and arrive at something definitve, only to be treated with lasix and cardiac meds. It's the threat of being sued, and also the off chance something else could be going on, that causes thousands of dollars worth of tests.

What was the price difference?

Patrick, I had to use Anthem estimate cost tool recently and it's getting better. I wrote about in a blog post a while ago: http://www.treatmentreport.com/blog/2011/06/repost-review-of-anthem-bluecross-%E2%80%9Ccompare-facility-cost-and-quality%E2%80%9D-tool/

zzyzzx says

What was the price difference?

The dog's meds were $20, the tests would have been $500. He lived another 3 years, chasing balls and being obnoxious. The dog loved little kids - so I'd have to go to the neighbor's house to find him. He allowed little girls to dress him up and went bike riding with neighborhood boys (after my kids grew up). He was a trip.

You know your dog is more popular than you when he gets invited to the neighbor's 7 year old birthday party - and you weren't. I paid the kid back for not inviting me - bought him a basketball that the dog stole from him and herded all over the neighborhood.

Treatmentreport,

I think HealthNet has a similar tool. Haven't used it, though.

Amazing how big the spread is between $3k and $12k, roughly. What could be the reason?

Edit: Actually, I don't know whether they do cost comparisons between multiple vendors. Maybe they provide just one cost estimate.

justme,

some hospitals just have pricing power and their is nothing an insurance company can do to them. I believe that it's good marketing/reviews that make people want to go there and the insurance has to pay up higher rates. I know someone that worked at an insurance company negotiating with providers. He said that some hospitals were notoriously bad about their prices.

For simpler procedures such as ultrasound, outpatient facilities are always cheaper than in hospitals one that tack on a bunch of fees.

Hi Patrick,
A friend who is uninsured had the same question. He went to get an overall check up from a dermatologist and the doc he saw told him he had a mole that should be removed. Cost: at least $250.

He decided to get a second opinion. The second one didn't think it looked that worrisome, measured and photographed it, told him to check the size in a few months and see if it grew. This was a few years ago. My friend still has the mole.

This friend has a regular meetup to educate people who are uninsured about taking care of their health, and how to minimize costs to the docs. (He takes superb care of his health.)

I've decided to just see a general practitioner for now, since that should be 100% covered by my insurance as my annual physical. And I can ask him about a bunch of other stuff too.

You can go to the doctor and get it 100% covered?

One annual physical, yes. Maybe I should confirm that before going.

You should be asking what type of mandatory tests that they will make you take to jack the bill as well.

You can know how much a consultation costs.
Your treatment cost is unknown, or whether or not you even need treatment.
1. minor surgery 2. minor plastic surgery for scar 3. biopsy 4. reading biopsy with stained tissue samples.
Of course doing nothing is always an option.