“I can make more generals, but horses cost money.“
As expected, there are many comments and letters this morning about money. Many ask that reconsideration be given to accepting insurance assignment. I have promised transparency and money is always one of the hardest things to talk about openly, but here goes.
For a number of excellent legal reasons, the institute and the medical practice are separate entities. There is NO money to float the expenses of the clinic while waiting for collections. So if there is no cash coming in immediately, we can’t open. It’s that simple. We have no subsidy. We may be able to revisit accepting insurance later, but for now, if it isn’t fee for service, there will be no clinic. I wanted to accept insurance. Everyone at the WPI wanted to accept insurance. It isn’t possible at this time.
The idea that the institute should fund large scale clinical trials is not realistic, since the government has no interest in funding XMRV research and the drug companies won’t go to work until the detection/causation issues are worked out. The funds actually need to flow the other way, from the clinic to the institute. The reality is that the patients are going to need to fund the research. Not fair, but true. So yes, once again, the patients get screwed. Money has a way of highlighting difficult reality.
People have asked if we could charge a higher copay for Medicare/Medicaid patients. It is illegal to balance bill federal insurance. Also accepting Medicare/Medicaid is an all or nothing proposition. You have to play completely by their rules or opt out all together. They don’t allow a middle ground. The government thinks a 20 minute visit is adequate, particularly since there is no treatment. We are not going to fix the system; it is broken and cannot be fixed in it’s current form.
I am assuming that everyone realizes that paying the provider is only part of paying the bills. Even if I could figure out how to fund the startup, and even if we used PAs instead of doctors on the frontline, the numbers don’t come close to working out. Personally I prefer PAs, because in general I don’t like doctors and, as a group, PAs tend to be more compassionate and detail oriented than doctors. However a physician is still necessary to supervise and bill for PA services. Also insurance won’t pay for anything telephonic and that will likely be a significant part of follow-up care. Mid-level practitioners would make it possible for ongoing care at a distance to be less expensive.
There is clearly a huge need for a consultation service for patients who can’t leave home. It is illegal to prescribe for a patient that has not been physically seen within a period of time, as it should be, but we will interface with local doctors to help encourage appropriate care. Eventually, we would like to partner in some way with like-minded local physicians to become satellites of sorts. Care needs to be available everywhere. All suggestions will be considered.
Lots of mail about how to get cheaper doctors from overseas or other kinds of discounted help. People have made suggestions such as using PAs for poor people and doctors for rich people. I can tell you clearly now, nothing like that is going to happen. The providers will be of the highest caliber or we will not open. There will not be two tiered care. I am unwilling to deal with the administrative difficulties of a sliding scale. But there will be a wait list for free care. The physician group will donate a percentage of time to patients who cannot afford to be seen – percentage to be determined when we have some real numbers to look at. We will ask that patients who can afford it donate for patients who cannot pay. Any ideas about how to fund for this group of patients is appreciated.
Rest assured that I too have lived the downwardly mobile life of a CFS patient. When I left practice, we had substantial savings that is now gone, having spent an unbelievable amount of money on $500/hr doctors and uncovered IV antibiotics for two people. I am determined not to do that to others. I hereby promise that nobody is going to get rich on the budget I’m putting together. Salaries will be fair, but we are looking for people for whom it is more than a job. The purpose of the clinic is to treat individual patients, but because of the translational medical approach that will be engendered by existing in concert with the research lab, there is a bigger purpose as well.
There will be no attempt made to “entice” patients to travel to Reno in order to make money, as someone put it in an email. Success would mean no need for patients to travel. Time will tell whether we offer anything new and different or not. I share the dismay of many as to how ineffective prior attempts at improving outcomes have been. One of the most upsetting things to absorb from the epidemiological study that is my mail is that the patients who have avoided doctors and expensive treatments have generally done better than many who have pursued endless aggressive experimental treatments. My impression is that the chronic Lyme patients are sicker and have more pain than the CFS group. That may have something to do with Borrelia burgdorferi infection, or it may have more to do with all the antibiotics these patients have been exposed to. Which doesn’t mean that antibiotics aren’t an essential part of treatment for some. As I’ve said before, I am not against the use of antibiotics, any more than I am for the use of antiretrovirals. I am for what works that doesn’t harm. I am in favor of making all treatment options available and tracking response in collaboration with the research lab. The goal is to develop a coherent approach to treatment that is finally informed by research and understanding the nature of the disease.