What's a fair unit rate?

[BDanes]

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Considering all this new talk of the government system and negotiating rates with private insurance, I was curious as to what you guys thought would be "fair".

Obviously Medicare is **** rate=$20/unit billed.
For me, my states medicaid is around $32/unit and most private insurance at $80/unit. Some at $45 and workers compl about the same.

So...with such a discrepancy I was wondering what you all thought.
Sometimes I wonder if it would be better to set a bundle rate for a procedure, or if it's best to stick with units. The problem is that even using units, Medicare refuses to pay out on some (P status and set fee for blocks, etc).

We all know that the gov't will lowball everything they can and the insurance companies will follow. It already happens. If I do a patient 65 or older the private companies pay MC rates--which is BullSh*t!!!

What do some of you who've been out for a long time think? What would be the best system for us? What rate would you be happy with if it was a single payor system? I'm thinking minimum $40/unit across the board and pay out for the units billed.

 

[coprolalia]

Tell us what your current blended unit is. And, don't lie.

No point in having this discussion without your starting point, Planktonmd... errr.... BDanes.

-copro

 

[RabbMD]

32 for Medicaid omfg.... My liberal supposedly rich state pays $13-$14. yes that means $17-$18/hour for a labor epidural.

 

[BDanes]

Why does it matter what MY blended unit is? I am asking what people nationwide feel would be a fair dollar amount/unit for our services if we are forced to go to a single payor system.

I don't know what my blended unit is, but I think it is probably good. I would say the bulk of my cases are made up of the $32/unit variety with about 60/40 between MC/Private for the rest. I am guessing my blend would be around the $40 mark.

I don't work for a group and am not on salary.

 

[coprolalia]

Why does it matter what MY blended unit is? I am asking what people nationwide feel would be a fair dollar amount/unit for our services if we are forced to go to a single payor system.

I don't know what my blended unit is, but I think it is probably good. I would say the bulk of my cases are made up of the $32/unit variety with about 60/40 between MC/Private for the rest. I am guessing my blend would be around the $40 mark.

I don't work for a group and am not on salary.

The point is that, for some reason, practices tend to guard this information very closely. What YOU get is relevant to this discussion. Since you're not working for a group, you really should know what you're bringing in... unless you're not doing your own billing (in which case you most definitely should know exactly what that number is, unless you completely trust - haha - the person doing the billing for you). Anyway, this info is a starting point as to what's "fair" under a single-payer system.

Our blended unit, depending on quarterly case mix, is about $40-50 dollars. I think that is probably pretty average, although I've heard some groups can get up to $60 on a blend which I think is amazing. We negotiated different start-up units depending on payer and case-type (and, stop saying "payor"... I don't know where that comes from).

Regardless of what a single payer ultimately pays us, the key is efficiency and how you negotiate supplemental coverage with administration. So what if you only get $25/unit from Uncle Sam? You tell them, collectively, that you don't touch the patient without a fair start-up unit rate. Then, if you can get a case done quickly with minimal issues in the post-op period (I mean, the part YOU control), then you can make some bank.

Furthermore, it also depends on what you negotiate for what I call "luxury" subsidies with the hospital... they want you to cover airways? Fine. Pony up. They want you to put lines in the ICU? Okay, not only will I bill for the individual service, but you're going to subsidize that coverage too, Mr. Administrator, if I'm going to be running around the hospital. That should, overall, factor into your "blend", depending on how you do your accounting, even though there is a set fee-for-coverage (in addition to what you bill).

Not every group shares this information, Planktonmd... errr... BDanes. I'm lucky that we have a group that opens the books and has been pretty up front about teaching me about this stuff since I got here.

Therefore, I don't think it is really 100% dependent on what a fair "unit" is, although everyone should know this information, as it should be what you can negotiate on units for start-up, subsidy for additional services covered, and overall what you can bill for individual procedures. That all ties in with efficiency in delivery of care, which is where I think this is going to shake out.

Having said all of that (and why I think what you are getting for a blended unit matters), I think a "fair" unit in a major metropolitan area is probably $55/unit. If the government isn't willing to pay that, then we are going to have to be able to negotiate a fair start-up set unit per case type that will recoup the differences in what we're now making.

In the interim, get better at what you do - everyone. Those clinicians who can't get the job done quickly, safely, comfortably, and with minimal complications are going to get marginalized and eventually replaced.

-copro

 

[coprolalia]

In the interim, get better at what you do - everyone. Those clinicians who can't get the job done quickly, safely, comfortably, and with minimal complications are going to get marginalized and eventually replaced.

Let me expand on this...

If it's routinely taking you 15 minutes or more to put in a labor epidural, YOU'RE IN TROUBLE.

If it's routinely taking you 10 minutes or more to put in a central line, YOU'RE IN TROUBLE.

If it's routinely taking you 20 minutes or more to put in a fem/sci block, YOU'RE IN TROUBLE.

If it's routinely taking you 5 minutes or more after the last stitch goes in to wake a patient up, YOU'RE IN TROUBLE.

If your patients are routinely puking in the PACU, YOU'RE IN TROUBLE.

If you're routinely holding up any surgeon in getting his/her job done, YOU'RE IN TROUBLE.

MARK MY WORDS! GET BETTER, OR YOU'RE GOING TO GO THE WAY OF THE DINOSAURS!

-copro

 

[BDanes]

First of all, I will continue to use payor if I choose. Look it up. Secondly, I am not Plank.

Now, as to the topic at hand, I am guessing then that my blended unit is significantly higher than $40. This is if I base it on subsidy I recieve from the hospital for calls. I can't give a number due to the fact my accounts recievable hasn't built up enough to give an accurate estimate.

Everything from my billing company is transparent, and I have no worries in that regard.

 

[Arch Guillotti]

Secondly, I am not Plank.

this is true.

 

[coprolalia]

this is true.

He's someone else's sock puppet then.

-copro

 

[dhb]

Let me expand on this...

If it's routinely taking you 15 minutes or more to put in a labor epidural, YOU'RE IN TROUBLE.

If it's routinely taking you 10 minutes or more to put in a central line, YOU'RE IN TROUBLE.

If it's routinely taking you 20 minutes or more to put in a fem/sci block, YOU'RE IN TROUBLE.

If it's routinely taking you 5 minutes or more after the last stitch goes in to wake a patient up, YOU'RE IN TROUBLE.

If your patients are routinely puking in the PACU, YOU'RE IN TROUBLE.

If you're routinely holding up any surgeon in getting his/her job done, YOU'RE IN TROUBLE.

MARK MY WORDS! GET BETTER, OR YOU'RE GOING TO GO THE WAY OF THE DINOSAURS!

-copro

Yay i'll survive in coproland....

btw what's up with the paranoia?

 

[Arch Guillotti]

He's someone else's sock puppet then.

-copro

lol, uh no.

Get over yourself😀.

 

[EternalMD]

Yay i'll survive in coproland....

btw what's up with the paranoia?

he's trying to be like jet... all he needs now is to have progressively larger sized font and use the word Deft in as many ways as possible

 

[Coastie]

what state pays $32 for medicaid!? 😱

 

[deleted87051]

what state pays $32 for medicaid!? 😱

Nevada. Here in California it is about $12 and will probably decline.

 

[urge]

Let me expand on this...

If it's routinely taking you 15 minutes or more to put in a labor epidural, YOU'RE IN TROUBLE.

If it's routinely taking you 10 minutes or more to put in a central line, YOU'RE IN TROUBLE.

If it's routinely taking you 20 minutes or more to put in a fem/sci block, YOU'RE IN TROUBLE.

If it's routinely taking you 5 minutes or more after the last stitch goes in to wake a patient up, YOU'RE IN TROUBLE.

If your patients are routinely puking in the PACU, YOU'RE IN TROUBLE.

If you're routinely holding up any surgeon in getting his/her job done, YOU'RE IN TROUBLE.

MARK MY WORDS! GET BETTER, OR YOU'RE GOING TO GO THE WAY OF THE DINOSAURS!

-copro

Says your 4 months of attending experience?

Don't you have better things to do like creating another one of those "I'll blow you if you blow me" threads?

 

[BDanes]

No kidding! I try to start a thread that could be informative or provide a platform for discussion and the D-bag who hijacks almost every thread is at it again. Since I am relatively new as an attending myself I wanted some opinions from those with more experience than myself.

I personally feel I have a good gig, but we are all in this together.
I am curious what some people around the country are getting for their "blended" unit and what they feel would be fair based on our level of expertise if we are forced to have a single payor system.

We have all heard from the self-professed know-it-all, and know where she stands.

Other opinions, or thoughts for discussion?

 

[kmurp]

I think that if you are significantly above $40/unit blended average you are doing well. I seem to recall MGMA average numbers around 43-45/unit in their last survey. You can purchase the annual MGMA survey from their website but it isn't cheap. I don't know your payor mix but I do like that medicaid rate. Our is $10/unit. It was $5 until they doubled it around,, when was it, 10 years ago or so?
By the way, it's just my opinion but I don't think that it's the hospitals' responsibility to make up any shortfall in earnings that may come from a "government option". Where I live, they don't really have much excess money to throw at us. Were I (or my group) to tell our hospital that we wouldn't "touch" a patient without a "fair" startup rate (not even sure what that is) we would be out on our ass: and one could argue deservedly so. That is in the setting of a level playing field where we all deal with a "public option". I do realize that currently there are locations with high levels of government payors that cannot retain staff without a subsidy. I just believe from common sense and speaking someone with a national perspective on this issue that the subsidy pendulum will swing back.

 

[BDanes]

What do you mean by the subsidy pendulum will swing back?

 

[pgg]

If it's routinely taking you 15 minutes or more to put in a labor epidural, YOU'RE IN TROUBLE.

I can unwrap a kit, stab her with a needle, and tape the catheter in much less than 15 minutes ...

... it's all the ancillary crap that takes so much time. Gotta go to the Pyxis and get the drugs, gotta do the consent (and I feel obligated to spend at least a few minutes talking to her about epidurals/c-sections before I stab her in the spine), gotta go find labs, gotta get her sitting up and positioned right, placement is quick, gotta prime & program the pump, gotta move the IV pole and hang up the pump and plug it in, gotta do the chart (same paperwork as an OR chart with a bunch of boxes to tick, vitals to document, a narrative to write).

Some of the nurses are better than others at having CBC results ready or the patient positioned when I arrive. But I don't know what else to do to speed up the mess of crap that surrounds actually doing the epidural. I do CSEs on just about everyone and I just hit run on the pump as I leave, so it's not like I'm sitting there incrementally bolusing the epidural for 10 or 15 minutes.

I'm pretty fast at most everything regional, having done a lot of almost everything as a resident. But I can't get out of a labor room in under 20 most days.

How do you get 15 minutes as your ceiling? Are your nurses preparing for your arrival? What kind of charting do you do? Do you not talk to the patient before starting? This is one area where I feel slow but I don't see how to make any of it go any faster.

 

[pgg]

He's also gotta step up to the mic with micatin.

And get mod powers so he can snipe trolls with a 30-06 ...

 

[dhb]

This is one area where I feel slow but I don't see how to make any of it go any faster.

In your situation it's impossible to do better the fastest i've done is 5min this is without talking to the patient no consent and no paperwork. I just said hi i've got to start a lung transplant in 10min so we're gonna make it short 😀 .

I remember Mil saying he had a hard time cracking the 15min mark...

 

[RabbMD]

You left out the worst time killers: going to the bathroom right when you are opening your kit and the patient taking forever to sit up and consent because of contractions.

 

[militarymd]

In your situation it's impossible to do better the fastest i've done is 5min this is without talking to the patient no consent and no paperwork. I just said hi i've got to start a lung transplant in 10min so we're gonna make it short 😀 .

I remember Mil saying he had a hard time cracking the 15min mark...

yep...in my system...I break the 15 minute mark rarely....95% of the time I'm less than 18 minutes.

If I could get the OB nurses to do a lot of the crap that I do that is NOT related to actually talking to the patient or doing the epidural, I can probably be between 10 and 15 minutes if it is not a complicated patient.

 

[BDanes]

Now that this thread has morphed into a one that has nothing to do with the original topic......

We are always limited in efficiency by the weakest link--usually the nurses.
I learned in residency to always confirm that patients had labs in the chart, bolus in or running (despite lack of evidence), and had the patients sitting up with supplies in the room.

If I went into the room and the above were not ready as I was told I would ask the nurse in front of the patient if she had what was missing. Usually this was done in a way to make it seem as if she dropped the ball in front of the patient. Usually, they would have it corrected and would call and tell me everything was ready without me asking for it.

If they failed to learn then I would just delay going to do the epidural until absolutely necessary. Passive aggressive? Yes. Patient suffering? Sometimes.
But an epidural is a luxury, and that's a fact.

This, combined with no charting until epidural was running made my speed increase dramatically. Private practice is a bit different. I can't really be an a-hole to nurses as it's counterproductive.