A quandry involving Medi-Cal, going from paying badly to not at all

[Tobra]

The state legislature has decided it would save them money to drop podiatry, optometry and dentistry. As of July 1st, they go from 10 cents on the dollar, to nil. Medi-Cal is the state medically indigent program.

For the ER stuff, don't have a choice, gotta go, but if the person has been admitted and it comes across as consult on an inpatient, you can decline. Generally I do the no pay stuff when they call me, but I am a bit torn; doing free stuff for the state of California is particularly distasteful to me. If I don't handle stuff, it ends up in the Chief of Surgery's lap, and I don't like doing that to Mike, I like Mike. I need to do a bit more research on this part. It may well be that if I am the surgeon, they don't pay the anesthesiologist or the hospital either. If this is the case, the orthopedic surgeons will be bummed, because they will end up doing all the crap foot cases at the hospital.

I also have a fair number of Medicare/Medi-Cal patients, where the Medi-Cal pays the 20% Medicare co-pay. With most of them, I figure I bill them, they can't afford to pay and I write off the loss

[Noah930]

There are a couple local hospitals that will pay Medicare rates for all non-insured (and let's face it--in your case, MediCal is effectively non-insured) patients. Just bill the hospital medical director directly. Or, at least, that's what I'm told. I haven't gone through with it, yet.

Otherwise, consider all those non-paying patients (which are the majority of ER patients) as your "community service."

In the meantime, I'm still waiting for my California tax refund...

[turbo6bar]

My fear is an ever-widening single provider program will drive away financial incentive for doctors. This is a serious potential problem, and the entire nation is to blame for setting up the environment.
Jurgen

[Rikao4]

so you work for free..
this must be the new health care plan O is talking about..
amazing plan..

perhaps you can write 'see community service' on your next tax bill...

Rika

[Nathans_Dad]

I work for free all the time. About 10% of my admissions are "private pay" which usually equates to "no pay".

I keep saying that the gubmint should let docs deduct the cost of their services for indigent patients off their taxes as a charitable contribution.

[island911]

Hey, stop complaining ...these a politicians are trained professionals. They know BEST how you will spend both your time and your money.

Seriously, we have an epidemic of power-drunk politicians. Can ya triage those folks to the front of the line? ....maybe some electro-shock therapy?

[Moses]

Tobra, are you a podiatrist? I'll bet we know some of the same people.

I don't take MediCal. I end up providing the care for free. Luckily it's not too frequent. Choosing when and to whom we give away our care is far more satisfying.

Soon, California will take the Massachusetts approach; if you want a license to practice, you WILL take MediCal. Yep. We will be indentured servants of the state.

[sammyg2]

I don't work for free and don't think you should either. Did those folks who want free care help pay for your very expensive, very long, and very difficult education?

I do donate time and money to charity which is what you are doing so that's your call.
If I were in your shoes I'd do what I could to limit that charity to 10 or 15%.

[Porsche-O-Phile]

All of the liability, none of the pay...

What a great-sounding deal!

Precisely why I'm not doing architectural work anymore.

[mikester]

I imagine it is difficult being in a Dr's shoes - knowing you can help someone, wanting to do it but knowing that if you don't get paid for it you can't afford to keep doing it. Especially in CA.

I don't have any suggestions really because if I were in those shoes I am sure I would have the same questions Tobra raised in his initial post. Provide care knowing full well you won't get paid or don't.

I can sympathize with your distaste for the way the CA government is handling things and the state of our health care system.

There are a great number of inefficiencies I have witnessed as a patient in the way billing is done in the state run institutions. One example is that it took 10 months for us to receive our first bill on an ER visit for my son. The thing is, they never billed our insurance (which we gave them at the time of service), had they done that they would have been paid immediately. Unreal and just the tip of the iceberg - 10 months!!!

[Tobra]

I do plenty of freebies now, probably 50% of the ER calls. Fortunately, they don't call too often, but if I see 9164542222 on the caller ID, I always cringe. I actually lose money on them, because you still have to pay for gas you use to drive to the hospital to provide free care, go figure. Supplies for dressing changes can add up too. This guy I am seeing now probably owes me north of $2500. Only chance I see any of this is if he hits the lottery, and that would be a slim chance. Carl is a nice guy with some bad metabolic disease and no insurance.

Last ER call was a 31 yo IDDM pschyzophrenic who walked a hole in her foot, got a nasty abcess, but surprisingly did not have a bone infection. I get to stick a knife in her and clean it up, which turned out to be a waste of time. I told her every single day for a week and a half that she would get her leg cut off if she did not stay off her foot, and she was up on that MFer ever single time I rounded on her. She was in the hospital for that long because they could not get her blood sugars under control, imagine that. Only way we afford healthcare for everybody is for people like her to expire promptly.

[red-beard]

Originally Posted by Moses

Tobra, are you a podiatrist? I'll bet we know some of the same people.

I don't take MediCal. I end up providing the care for free. Luckily it's not too frequent. Choosing when and to whom we give away our care is far more satisfying.

Soon, California will take the Massachusetts approach; if you want a license to practice, you WILL take MediCal. Yep. We will be indentured servants of the state.

Why stay? I am serious. What is it that is making you stay under these circumstances? The tolerance for the crap you put up with in California amazes me.

[Tobra]

I like the climate myself, it is only relatively recently(last few decades) that they have gotten out of hand on spending. When you get established, you don't really want to pull up stakes, which is just what I did coming out here, but had extenuating circumstances.

This latest deal will not last too long, they will figure out relatively quickly how much cheaper it is to go the pay me now, rather than pay me later route. My national association is working on some things that will fix this on the federal level, which will remove this authority from California, because it is federal dough, administered by the states.

[red-beard]

I understand. When my sister moved to San Diego in the late 1980's it was a wonderful place. 14 years later when I moved there, it was completely different. The "little towns" along the coast were now one continuos suburb. The only separation between San Diego and LA was/is Pendelton.

No one has the balls to stand up and change things. It will take California going bankrupt to make the necessary changes. But that will only fix the financial issues. Californians have allowed many of yours right to be eroded. Those will be even tougher to get back. No financial bankruptcy is going to remove the stupidly onerous gun laws you have.

I don't know what we all are going to do, if a single payer, Medicare type system is attempted in the US. I do not expect it will be a good thing for doctors.

[Tobra]

holy crap you sold your car

[Noah930]

Originally Posted by red-beard

Why stay? I am serious. What is it that is making you stay under these circumstances? The tolerance for the crap you put up with in California amazes me.

Another factor in staying is that it's surprisingly difficult to get up and go. Actually, getting up and going is not too difficult (though you do have to pay tail-end malpractice coverage--You have to pay malpractice for all the lawsuits that might come in after you leave your practice. Effectively, from a purely business standpoint, you can't leave unless you pay to leave.)

But getting set up in a new shop is somewhat difficult. Most doctors have hospital privileges. You can't just walk into a hospital and work, even if you have a license in that state. So, backing up, you have to get a license in the state for which you want to work. That will take (usually) 4-8 months.

Then, you have to get hospital privileges. That will take another 6 months.

Before you can get hospital privileges, you have to have malpractice insurance. If you're in a high-risk specialty like Moses (OB-GYN) in an unfriendly state, that can run in the 6-figures. That's payable up front. No refunds for any unused portion. No pro-rating. So, before you can even start working, you have to pay malpractice while you sit with your thumb up your rear-end, waiting for hospital privileges.

Once you get hospital privileges, then you can essentially start seeing patients (though there are some practitioners who have offices, but no hospital privileges). Then, once you start seeing patients, it'll take usually 3 months or so to get paid for services rendered. So, after you've paid your hefty malpractice premium for the year, it will take at least 9 months before you start seeing any return on investment.

If you join a hospital staff, you usually have to tell them who's going to cover you when you're not on call or on vacation. That other physician has to be on the same hospital staff (or I suppose you can apply with a partner at the same time). Sounds reasonable, but it's a bit odd to go around a medical community, introducing yourself to people who are going to be your competitors, and ask that they back you (a stranger) up.

If you're a surgeon and expect to do procedures in a hospital, you also have to be "proctored" for a certain number of surgeries (by another surgeon of the same specialty, who's in good standing at the hospital) before you're allowed to operate on your own. They have to be there for those first few surgeries that you do. Doesn't have to be the same guy for all x number of cases. But you have to have all those first few cases covered. Again, sounds good and reasonable. But you're again asking a stranger (who's going to be a future competitor) to stand up and vouch for you, and risk his/her reputation and medical license. And you're asking them to come do it for free. It would be like opening up a new McDonalds, and asking the local Burger King to send over a few employees to watch over the McDonalds crew for the first couple weeks of business. I've never heard of anyone saying no to this type of request, but it's an unusual position to be in, nonetheless.

I'm sure every field of business has it's difficulties. These were just a few that I noticed about trying to start up a practice in medicine, however.

[Moses]

Exactly. The barrier to relocation is pretty huge.

[grudk]

The ER stuff goes with the territory, but decline the rest.

In my old digs, this is what our practice group did, and it worked out fine despite the indignation of various administration officials.

The work will always get done, somehow, just not by you. And you'll be happier, with more time to use productively.

When you provide free services, there will be unlimited requests for 'more.' Break the cycle.

[tabs]

Sounds like the MD's in Cali have the State for PROCTOLOGISTS....

[tabs]

Moses you beat me to it..your not indentured servants your SLAVES>...