Vol. 44 May 1, 2011 Why Can’t Medicare Be Like Visa?

May 1, 2011

Last week I made two purchases on the same day with my Visa card, one for $293 and one for $273, but the two transactions could not have been more different.

I spent $293 for three pieces of metal to repair line cutters on the two propeller shafts of my boat. The $273 was for a shot of the shingles vaccine, Zostavax.

At the marina, I told the parts manager what I thought I needed, and after a brief exchange he went back into the large storage area, brought out what I needed, showed me how to install them, and swiped my Visa card. I left with the parts, the receipt, the confidence that the parts would solve my boat problem, and the certain knowledge that the charge would appear on my Visa statement next month.

At the doctor’s office, I filled out the short registration/information form, was greeted by the nurse who ushered me into a small exam room, gave me the injection, and sent me back out to the front desk to sign out. And that is where all semblance to my other purchase ended. The receptionist began a little speech which sounded well-rehearsed but only because she delivers it 20 times on a vaccine day,

 “If you have Medicare Part D we can not bill your insurance. You may pay today with check, Visa, or Master card, and we will give you written instructions on how to be reimbursed by your insurance carrier. Here is the detailed receipt for today’s service that you will need to send in to your insurance carrier. Also, here is the list of the numbers they will require you to provide; our tax ID number, the physician’s  NPI number, the procedure code, and the National Drug Code number of the vaccine. Please note that there are 6 physician NPI numbers on this list, and we have circled the one you should submit as the supervising physician for today’s injection. You will need to go to your insurance carrier’s website to print out a claim form, complete it, and mail it in for your reimbursement of today’s charges. Don’t forget to include todays’ detailed printout even though you have provided much of the same  information on your carrier’s claim form. Keep copies of everything that you submit. Usually the carrier will reimburse you in about 60 days. Any questions?”

I had two…no, three immediate reactions.
1) what the hell?,
2) what is so special about this service that I need to do this instead of them?,
3) what if once a year all doctor’s offices did this for all their services to all their patients?
Boy, wouldn’t that be an eye-opener for patients!  Talk about transparency! A taste of the reality of what doctors’ offices go through every working day to get paid by multiple insurance carriers with different forms, review procedures, and deadlines might jumpstart a consumer campaign for single-payer health insurance!

But, I kept quiet and handed her my Visa card. She swiped it, had me sign the slip, and gave me a copy along with a detailed encounter printout, a page of instructions, a page with the required numbers, and a wish to “Have a nice day”. I went home printed the claim form on my carrier’s website, completed it (9 digits for practice tax ID#, 10 digits for NDC#, 10 digits for physician’s NPI#, two 5-digit procedure code #, and two 5-digit diagnosis code # ). There was no line to record one of the numbers, so I just wrote it on the bottom of the form. I attached the doctor’s office printout (being careful to follow instructions to NOT staple or paperclip any of the pages together), copied all the pages, and mailed it. The carrier’s website told me to expect them to take at least 30 days to process my claim. There was no note about when I could expect payment.

By the way, $46 of the $273.21 charge that day was for the physician. The rest was for the vaccine.

Why can’t that medical service transaction be as simple as the one for my boat parts?

Medical Services are too complex, and there are so many of them?
Have you ever seen a marina chandlery or more commonly an auto parts store? Shelves stacked with myriad parts, big and small, rising right up to the ceiling and a countertop piled high with catalogs and specification books that make the ICD-9 code books look like magazines. All  sharing space with a computer terminal usually on a swivel to make it easier for the customer to help spot the picture of the one part for the boat or car model he wants. No, complexity of inventory can’t be the barrier. Just think Amazon.com.

Fear of fraud?
By the patient? My doctor’s office staff knows me by sight, but I still have to confirm my date of birth and Medicare number every time I go in. On the very first visit I had to show a picture ID. By the doctor? In 30 days I will “audit” the charges on my Visa bill. I could do it the next day on-line if I wanted to. If I don’t agree or think that something is amiss, an email or a phone call to Visa will put it on hold. If I didn’t challenge or question the charge within 30 days, Visa could let Medicare know and Medicare could transfer the same amount as a credit to my Visa account. I’ll get to see the correctness and timeliness of that credit in my next Visa bill. If several patients reported charging problems with the same physician or office, Visa would be all over them.

If  Visa can call me within 24 hours to verify my purchase of diesel oil at a marina two states away from my home state where I had purchased oil just two days previously, I would expect them to be able to set up programs that would flag potential physician fraud. Certainly the current government and insurance carrier computer programs that have missed millions of dollars of fraudulent charges, in Florida alone, are nothing to brag about.

Too expensive?
The 7%  that Visa charges merchants and retailers for conducting transactions seems like a real bargain to me. If Citizens Bank can make enough profit on the $20 pre-payment “float” of Fast Lane, Visa could probably make an acceptable profit on the “float” from a $50 annual fee for health insurance transactions.

Lack of standard pricing?
Visa seems to be able to handle that quite well now among different airlines, hotels, catalog stores, and everyone else with a weekly special, redeemable coupons, and the like. Of course, a national standard, or at least a regional one, for health services pricing might make everyone’s life a little simpler, and easier to monitor.

Inertia, or fear of changing how we do things now?
Many hospitals, physcians and more than half of consumers currently favor a single-payer system, not because they are social liberals, or muddle-headed do-gooders, but because they are exhausted by and fed up with our current complex, inefficient, and bureaucratic payment system that is so easily manipulated by the insurance companies for their own benefit.

WHADDAYA THINK?    Take this poll to let me know.

Volume 8 November 1, 2009 Bugs and Drug; Bugs AS Drugs

November 1, 2009

hub “The ‘no handshake’ policy of the NBA is ridiculous when you think about the amount of bodily contact under the boards.”

-Jerome Klein, MD Professor of Pediatrics, Boston U. Med. Ctr.
Pedi Infectious Diseases Conference, Oct. 24, 2009
commenting on the Oct. 1, 2009 request by the NBA that players NOT shake hands before a game to reduce the spread of flu.

Factor by which microbial cells (bacteria) in your body outnumber your own cells: x 10

  • In other words, only 10% of the total number of cells in your body are human cells.

Number of species of infectious bacteria on physicians’ ties in a 2004 study: at least 1                  Now you know why pediatricians used to wear bow ties. Studies of physicians’ white coats are underway.
Number of bacterial species on the palm of your hand: >150
Per cent higher the bacteria count is on female undergraduate student hands as compared to male undergraduate hands: +50%

  • The authors of this study tread very lightly here and cautiously speculate that it might be related to use of cosmetics and lotions. (1)

Methicilin resistant staph aureus (MRSA) can be found in sand and salt water.

  • “We should not fear the beach. We can shower before we go into the water, and we can shower when we come out of the water. That way we can protect ourselves.” Dr. Plano (2)

Factor by which the number of bacteria found in shower heads exceeds that found in “background counts” of air and water:  x 100     (3)
Per cent of those that were staph bacteria:  2       None were MRSA, and there was no evidence for infection from this water.

Per cent of 156 children who got pertussis (whooping cough) that had refused the vaccine: 11%

  • Herd immunity (the concept that the unvaccinated are protected because the vaccinated don’t get the disease) does NOT work.  (4)

Per cent annual return on investment (ROI) for providing vaccinations of preventable diseases in low income countries:  18    (5)
Number of databases currently tracking vaccine side-effects:  3

Per cent of U.S. physicians who prescribe antibiotics for ear infections: 80%  (6)
Per cent of Polish and German physicians who do: 40%
Per cent of children in the U.K. with mastoiditis who did NOT have a preceding ear infection: 66
Per cent of total world-wide antibiotics attributed to treatment of acute ear infections: 37%

Chance that head lice will hop or jump from person to person or live on your pets: 0
Chance that an adopted child from Russia, China, or Gutemala who tests negative for TB when first tested upon arrival to U.S. will then test positive after 3 months of improved nutrition: 20%

Per cent reduction in runny noses of 326 children in China who were given lactobacillus acidophilus (a probiotic often contained in live culture yogurt) twice a day for over 6 months: 27 – 51    (7)

  • A probiotic is a live microbe that is ingested orally in great numbers, 1000,000,000 per dose several times a day, to enhance your health. Studies to assess their benefits are increasing as people look to probiotics as an alternative to anitbiotcs and other medical drugs.
  • It is a bit of a wonder to me that some parents who oppose vaccinations for their children with inactivated, killed cells  because of the “foreign proteins” readily feed their children millions of live cells of “foreign proteins” (probiotics) to make them healthier.

Reduction of diarrhea duration by those using probiotics: 1 day
Per cent reduction in colds, diarrhea, and colic of infants given synbiotics for the first 6 months of life: 0  (8)

  • A synbiotic is a combination of a probiotic (live microbial organisms) and a prebiotic (indigestible nutrients that enhance normal gastrointestinal bacteria)

Per cent reduction in use of antibiotics by the infants who received the synbiotic :  20%
Number of undesirable side-effects or unexpected changes in growth patterns in infants fed synbiotics: 0

  • Synbiotics may not provide big benefits, but at least they do no harm.


1. Proceedings of National Academy of Sciences 105:17994-9
2. American Assn. for the Advancement of Science Annual meeting, Chicago, Feb. 12-16 ,2009
3. Proceedings of National Academy of Sciences 106:16393-9
4. Pediatrics 2009 June 123:1446
5. Bull WHO 2008 Feb 86(2) 140-6
6. Many of the facts to follow were reviewed at the Annual Pediatric Inf Dis Conference, Boston U. MC, Oct 24-25, 2009
7. Pediatrics 2009; 124: e172-e179.Leyer
8. Pediatrics 2008; 122: 8

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