Thoughts about this California Ruling?

[NPEMTIV]

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I was curious what others thought about the California Supreme Court's Ruling preventing balance billing. I find it disheartening that doctors are constantly being ruled against and HMOs are making millions. Is this just going to keep spreading?

Anyhow, here's the article I'm talking about.
http://online.wsj.com/article/SB123147400201867391.html?mod=googlenews_wsj

 

[Old_Mil]

I was curious what others thought about the California Supreme Court's Ruling preventing balance billing. I find it disheartening that doctors are constantly being ruled against and HMOs are making millions.

It is very disappointing. Forget about HMOs - it's dsheartening that doctors are constantly being ruled against when the lawyers and judges that rule against them are making bank.

Is this just going to keep spreading?

Probably.

 

[WilcoWorld]

I wouldn't mind this ruling much if I thought that the courts would back it up by saying that the insurance companies would have to come through with the funds, but for some reason (lobbyists) I doubt that's going to happen...

 

[Aloha Kid]

This is also known as HIGHWAY ROBBERY. Wouldn't it be awesome if we could all go on strike for just ONE DAY!!!

 

[docB]

The ramifications of this ruling for EM are without question very bad. Be afraid. Support NEMPAC. Call your legislator but I think we're screwed on this and when this comes to your state you'll take a ~10% hit with more to come as insurers and HMOs start to negoiate with this additional power base to hide behind.

Interestingly there was a thread started in the Topics in Healthcare forum about this but it was started and responded to by several non-EPs who felt the ruling was a good thing and that balance billing is unethical.

http://forums.studentdoctor.net/showthread.php?t=589008

 

[NPEMTIV]

The ramifications of this ruling for EM are without question very bad. Be afraid. Support NEMPAC. Call your legislator but I think we're screwed on this and when this comes to your state you'll take a ~10% hit with more to come as insurers and HMOs start to negoiate with this additional power base to hide behind.

Interestingly there was a thread started in the Topics in Healthcare forum about this but it was started and responded to by several non-EPs who felt the ruling was a good thing and that balance billing is unethical.

http://forums.studentdoctor.net/showthread.php?t=589008

I wonder how many of the non-EPs you mention accept every patient without question? Must be nice not having EMTALA regulating everything.

Edit: i will definitely check out this NEMPAC

 

[NPEMTIV]

This is also known as HIGHWAY ROBBERY. Wouldn't it be awesome if we could all go on strike for just ONE DAY!!!

I'm typically a non-union man, but it seems to me with all I read these days that if physicians don't join forces and really stand up against this, and other injustices, that we're just going to wind up with nothing. Why is it that the physician is the provider, the one with the knowledge to perform the service, the one with the legal liability, and yet not the one making the rules? Who in the heck dropped the ball on this one???

 

[docB]

Who in the heck dropped the ball on this one???

No one really dropped the ball. It's just a situation that's got a lot of public support (eg. "Don't you think it's wrong that you would have to pay whatever outrageous fee some doctor charges you if your insurance won't cover it?") and is politically very attractive (eg. "I'm congressman Shrub and I stood up for you against those greedy doctors.").

I've said before, many times, the best way to sum up the American attitude toward healthcare is that people want the absolute best healthcare they can get without ever paying anything out of pocket.

 

[NPEMTIV]

No one really dropped the ball. It's just a situation that's got a lot of public support (eg. "Don't you think it's wrong that you would have to pay whatever outrageous fee some doctor charges you if your insurance won't cover it?") and is politically very attractive (eg. "I'm congressman Shrub and I stood up for you against those greedy doctors.").

I've said before, many times, the best way to sum up the American attitude toward healthcare is that people want the absolute best healthcare they can get without ever paying anything out of pocket.

True. I hadn't thought about it this way. Thanks!

 

[It'sElectric]

As a 3rd year med student, these sorts of rulings/laws are honestly frightening. It feels like it's all slowly snowballing into something so much bigger that will have us all looking back, thinking wtf happened.

I didn't get into medicine to become rich, but I certainly assumed I would one day be able to pay off my loans and lead a comfortable life one day. The more time passes, the less likely this all seems.

Is there any hope for the future? When will physicians band together and actually go on strike, rather than just talk about it? I think it will eventually (unfortunately) be a reasonable reaction to what's occuring.

 

[docB]

As a 3rd year med student, these sorts of rulings/laws are honestly frightening. It feels like it's all slowly snowballing into something so much bigger that will have us all looking back, thinking wtf happened.

I didn't get into medicine to become rich, but I certainly assumed I would one day be able to pay off my loans and lead a comfortable life one day. The more time passes, the less likely this all seems.

Is there any hope for the future? When will physicians band together and actually go on strike, rather than just talk about it? I think it will eventually (unfortunately) be a reasonable reaction to what's occuring.

Based on history it's less likely that we'll all band together and do something than that we'll all just be led into whatever situation emerges down the line. I think a socialized system with CMS running the show is the most likely situation on the horizon. We would then be paid less but I think it's likely that less would be expected of us. When you're just a government functionary you won't be expected to work more than 40 hours a week, benefits will be good, retirement early and liability less. Pay will likely be in the neighborhood of ~40% of current but that's not our decision.

It will always be hard or impossible to get docs to act as a cohesive group. For example the procedural specialties have always fought the cognitive specialties for reimbursement. Right now ACEP is fighting the emergence of the "Patient-Centered Medical Home" which is a concept for increasing reimbursement to primary care. ACEP is fighting it because of the fact that healthcare has finite resources and we don't want to see those resources taken away from EM (relavent article from Annals). So in that respect we have the EPs and the PMDs fighting over a carrot.

 

[EM2BE]

No one really dropped the ball. It's just a situation that's got a lot of public support (eg. "Don't you think it's wrong that you would have to pay whatever outrageous fee some doctor charges you if your insurance won't cover it?") and is politically very attractive (eg. "I'm congressman Shrub and I stood up for you against those greedy doctors.").

I've said before, many times, the best way to sum up the American attitude toward healthcare is that people want the absolute best healthcare they can get without ever paying anything out of pocket.

Yes, this would be great, but like everything, there is a price tag attached. I expect to get a bill every time I go to a doctor's office even though I pay a certain amount every month to the insurance company. I also know that if I use more than the insurance allows, I am responsible for paying my bills. It's like saying to a grocery store that you want to pay a certain amount monthly but go over that amount and expect to not have to pay a balance. I wish some people would have some sense.

/end rant.

 

[scottyT]

This ruling is indeed unfortunate, however, not all physicians seem to agree.

From another article http://www.mercedsunstar.com/167/story/631740.html
"A California doctors group, California Association of Physician Groups, released a statement in favor of the court's ruling. The group said the price that emergency room doctors charged for procedures was often much higher than what was reasonable and customarily paid to doctors contracted with insurance companies -- often up to double the customary rate."

It appears the crux of the ruling is to try and force doctors to negotiate with HMOs rather than directly with the patient. This sounds exceedingly difficult to me; I can't imagine a lone group going up against big managed health. The HMO has no legal obligation to pay beyond their plan allowances. They are, after all, not in a contract with out of network providers. With this ruling the patient is no longer required to be responsible for their accrued charges either.

I can see either one of two things happening in the near future:
1.) a ruling on what constitutes "reasonable charges" that may or may not be close to "reasonable."
2.) a flight of EM physicians to other states.

Luckily I won't have to worry about pesky things like business plans or profit because the whole mess will probably be socialized by the time I'm in practice.

 

[docB]

This ruling is indeed unfortunate, however, not all physicians seem to agree.

From another article http://www.mercedsunstar.com/167/story/631740.html
"A California doctors group, California Association of Physician Groups, released a statement in favor of the court's ruling. The group said the price that emergency room doctors charged for procedures was often much higher than what was reasonable and customarily paid to doctors contracted with insurance companies -- often up to double the customary rate."

Excellent point. That goes back to what I mentioned about doctors fighting amongst themselves rather than uniting against the common enemy.

It appears the crux of the ruling is to try and force doctors to negotiate with HMOs rather than directly with the patient. This sounds exceedingly difficult to me; I can't imagine a lone group going up against big managed health. The HMO has no legal obligation to pay beyond their plan allowances. They are, after all, not in a contract with out of network providers. With this ruling the patient is no longer required to be responsible for their accrued charges either.

You are correct in that the intent is to force the docs to work it out with the HMOs rather than the patients. The problem is that by ruling in this manner they have given the HMOs a huge advantage in negotiating future contracts. The HMOs (or any insurers really) can say "Take our paltry contracted fee schedule or well pay you even less as an out of network and you can't balance bill so sign or get bent."

I can see either one of two things happening in the near future:
1.) a ruling on what constitutes "reasonable charges" that may or may not be close to "reasonable."
2.) a flight of EM physicians to other states.

1.) Lawyers get to decide what is a fair fee for me to get. That's cool since the medical board sets lawyer fee schedules😛.
2.)This is what should happen but it won't. I think states should have the right to make stupid laws. It's the states rights libertarian in me. I also think that when they do something as stupid as this they should suffer the consequences and have all the EPs leave.

It'd serve 'em right to have all their ERs close due to lack of staffing. And this ruling applies to any doc doing emergency services. So staffing EDs with FPs or IM docs or whatever won't provide a work around.

It won't happen because CA is too attractive of a place for all the non-medical reasons. However the more they cut the closer they get to the tipping point where they really will feel the pinch. There are some good gigs in EM in CA. Spyder works there. I do recall that out of the 10 docs in my graduating residency class at UC Davis not one went into private practice in CA. 4 went to Kaiser, 4 left the state and 2 did academics (1 fellowship and 1 chief). The tipping point may be closer then the politicians there realize.

Luckily I won't have to worry about pesky things like business plans or profit because the whole mess will probably be socialized by the time I'm in practice.

Again I think you're right. This may all be moot in short order.

 

[NPEMTIV]

It's the states rights libertarian in me

It's good to see another libertarian. Since entering medical school I seem to have become the minority (even including Reps.)

 

[spyderdoc]

Yeah, we can expect to get about a 10% pay cut because of this new law. Basically we are going to be losing a month's worth of pay. Another way to look at is that we have been traditionally getting about 40% reimbursement on our billings (averaged across the board), so for every 10 pts we see, we get pain for 4! Now with this new law, we will only get paid for 3 out of 10 patients we see....Pretty disma, huh?

Cal-Acep is intending to fight it "all the way" to the top, so the battle is not yet over. One thing that we were going to consider was not not balance bill the patient, but direct bill the patient for services, and let the HMO reimburse them, but I understand that this is "illegal" as well under this law (but we are still looking into it).

It is just insane that something like this can happen. We as doctors just bend over and take it up the ***** everytime. And the lawmakers know that we will still see the patients, because it is in our blood to do the "right thing".

And now in Cali, the whole budget mess is going to probably raise our taxes somehow, so now increased cost of living, and decreased income....

Something definetly needs to change.

 

[GeneralVeers]

Physicians in general won't stand up for themselves. Medical school selects for a personality type that is compliant, follows the rules, and doesn't complain.

We're all screwed, and unfortunately ACEP can't influence the outcome enough by itself.

 

[RustedFox]

"... pay my loans, lead a comfortable life someday."

Exactly. and don't you let anyone talk you out of that. The public sometimes talks (whines) about how much doctors are "overpaid" for "not doing so much work". Bogus, I say. If I wanted to be just like everyone else, I wouldn't have gone to medical school and spent four years (and then residency) as an INVESTMENT in EDUCATION.

Sorry if I'm coming off as harsh, but I absolutely hate ignorance, and its been evident in so many different situations to me as of late. As if it weren't enough that every neo-hippie around me thinks that "healthcare should be free and should be a right", it seems that every jobless zero (with no intentions of ever turning an honest wage because it would cut into their grand theft and drug addiction time) is in my ED these days, asserting their right to everything under the sun, and then asking for pain meds. Sometimes I just want to grab one of them by the ears and scream "you won't ever pay a dime for your care, so you could either sit and f*ing wait your turn, or go and die in the streets. Take your pick."

Sorry, rough day.

 

[Hallm_7]

I could very well be wrong, but it seems you could get around this by refusing to accept any third party payer that you didn't have a signed contract with. If patient A comes in with Insurance A, don't balance bill, just charge patient A what is customary and treat them as if Insurance A doesn't even exist. Insurance A could reimburse Patient A as it sees fit. I could see how it would be legal for the state to require physicians to accept only what the insurance company pays if the EPs take anything from the insurance companies. However, if you don't even involve the insurance companies then how can there be any legal obligation to accept what that insurance company pays?

The way I see it, if the government forces EDs to see every patient regardless of future payment then liability should be waived unless payment is received within a reasonable amount of time and they should have no say as to what is charged.

The ruling as the article describes it is completely unsustainable because insurance companies can now charge whatever they please and the EPs must accept it.

Sometimes I wonder what a one-day work stoppage threatened for 6 months prior would do for physician reimbursement.

 

[Hallm_7]

Also, it seems like this ruling could be ignored for people who choose a specific hospital that is out of network. The ruling talks of being rushed to the hospital with no choice of which hospital it is, but if someone goes to Hospital X because of abdomenal pain/back pain/Headache/etc then they chose that hospital. It could very well be that a patient who chooses a hospital would not fall under this ruling.