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3/11/2013 6:00:00 AM
Wards: Insurance skews use of medical services
Sen. Kelli Ward (private practice) and husband Mike Ward (Kingman Regional Medical Center emergency room) discuss the state of health care and how it could be impacted by the Affordable Care Act.SUZANNE ADAMS/Miner
Sen. Kelli Ward (private practice) and husband Mike Ward (Kingman Regional Medical Center emergency room) discuss the state of health care and how it could be impacted by the Affordable Care Act.
SUZANNE ADAMS/Miner

KINGMAN - The husband and wife doctor team of Mike and Kelli Ward sat down recently with Miner Reporter Suzanne Adams, News Editor Alan Choate and Editor Rich Thurlow to share their views on the state of medical care as the Affordable Care Act is implemented. Kelli Ward, in her first term as a state senator, has a private practice in Lake Havasu City. Mike Ward is an emergency room physician at Kingman Regional Medical Center.

When we left off, the topic had shifted to health insurance.

Mike Ward: It's not really insurance. It's basically a scheme. It's a money-shifting scheme. It's not like regular insurance.

Certainly there are parts of the country where you buy flood insurance and you know damn well you're going to use it. So it's not the same thing.

But a lot of people buy health insurance with the intent to use it.

Miner: But how? What do you mean?

Mike: You're going to the doctor if you have high blood pressure. You know you're going to go to the doctor every three months and you're going to get prescriptions regularly filled.

Kelli Ward: And you're going to need blood work.

Mike: Ignore the people who have insurance as benefit through their employer that they just don't utilize. We know there are people out there that don't. But as a general rule, people utilize it just to use it. They have it to use it.

Kelli: An example is, between October and December you get a rush on people because they've already met their deductible for the year and they want to hurry up and get anything they can possibly get done.

"Oh, you know what? I'm turning 50 Dec. 15. Can I get my colonoscopy before the end of the year?"

"I need to get in and get my eyes checked. Can you give me a referral to where ever?"

"I want to go to the podiatrist. Can you hurry up and give me the referral before the end of the year?"

Miner: A person who has high blood pressure, diabetes, those are chronic conditions. Don't they need to go see a physician on a regular basis?

Mike: They do. I think the problem comes back to the first problem. The third party payer system causes those costs to be higher. Because when you have Medicare, Medicaid, Blue Cross, United Health Care, they all get billed the same. The expectation of payments is substantially less depending on who the payer is.

I would never say, "Just pay me this," because if I say, "Well, I know I'm only getting $50 dollars for this visit from Blue Cross. So I'm going to lower my rates to $50." Well, your reimbursement is going to go down too. So it's kind of a game.

Kelli: It's going to go down to $28.

Mike: Rates have gone up. In our group here, we don't have that many insurance plans that pay us our real charges. And people know, they get their explanation of benefits and they look at it and they go, "Wow, that bill was $125 and they got paid $17." And you see that, why would you charge $125 if you're only going to get $17? It's because someone may pay you that.

Do you know who it is? Who gets stuck with it? It's the cash payer. But you can't say, "This is our cash price," because it's fraud on those insurance companies by saying, "Well, if you have insurance, we're going to charge you $500, but if you don't, we're going to charge you $200."

Miner: Even though the cash payer pays $200, and you bill the insurance company $500 but you only get $200.

Mike: Correct. And that's why it's really a tragedy.

Kelli: If you cut the third party system out and it was basically a doctor/patient relationship again, the costs would plummet. Because No. 1 we wouldn't need to have this whole army of people who are billers and collectors, basically trying to get you the money you earned.

He's used the grocery cart analogy. Basically, if I go to the grocery store, I fill up my cart, I put it all up there, they ring it all through and they tell me, "It's $100." And I say, "Well, you know, I'm going to pay you $33, but I'm not going to give it to you for 90 to 120 days." That is basically the system that we work under in health care. You're delayed payments for services that you've already provided. At least if it was food they could take it back. For us, once you give it, they have it. So if they choose not to pay you, I consider that theft. But we can't even write it off as a loss of income. Basically, we just have to say, "We didn't get it." So the way laws are written are not designed to make things easy.

Mike: Not that we're whining. We make a good living. Our kids are far more spoiled than we ever were. I love being a physician. I love taking care of people. You know you always have those people that frustrate you in every business, when you're in a customer service industry. But for the most part, I love what I do. I couldn't see myself doing anything else. But the frustrations that go alongside that and how difficult it is to practice medicine - people should worry about that. Not because their doctor's going to complain and whine and be unhappy. But you need those people that say, "What a glorious and wonderful thing it is to do," to encourage the next generation that it is still a valuable thing to do.

What's happening in workforce development? There are two problems. One, colleges continue to rise in costs due to the availability of federally secured student loans. The costs go up. They're uninhibited. So people are getting out of medical school ... if you're lucky enough to go to a state school for lower tuition, but if you go to a private school, a lot of medical schools now are private schools. People are getting out of medical schools with $250,000 or more in debt. They have to be able to pay for it.

Kelli: But you also have to borrow money to live off of, because it's very, very difficult to go to medical school and work a job. You can do it in college. I worked two jobs and he worked at least two jobs through college.

But in medical school, the load is substantial and the expectation is that you're learning how to save lives. And the expectation is to be perfect. Not that we ever are, but we're always striving to do everything right because we realize how fragile life is and what we need to do to help people have the highest quality of life possible.

Having a job is difficult. It's not impossible. Some people have done it. It's not an easy task. So you're also borrowing money to live on that is guaranteed by the government.

Mike: One part of the problem is the rising cost of medical school education. It has to be paid for. People have to be able to come out of medical school with enough incentives to be able to pay off those loans.

And there are different mechanisms for going after that student loan money if you don't pay it. When you're a collector of the federal dime, they just won't pay you. So there's lots of ways to go after people who collect government checks for a living in health care.

The other problem is the whole funding scheme for graduate medical education. Kelli's the director of graduate medical education here at the hospital. So she understands a lot more of that.

Not only is there no workforce development, there aren't new funding mechanisms to help train the doctors of the future. Those positions are shrinking in some areas, especially in rural parts of the country.

Kelli: And the way they developed the formula. The East Coast, where medical education started, has a much higher reimbursement rate for training doctors than we do in the Southwest.

We are not getting nearly as much per resident to train the doctors that we need in our area. Because the studies all show that where you train, you are more than likely to stay near there.

Mike: The dollars that are used to train, to pay for graduate medical education. So it's not a private industry as a whole. Kingman Regional is covering the cost of some of those positions every year because they feel its important and we're glad they feel it's important. Because the only way we're going to get an infusion of physicians into our communities in primary care and emergency medicine, which is a very hard-to-recruit area, is to train our own.

Kelli: Last year we kept two of our family docs. They graduated last year. They stayed. They're actually working at North Country. And then we kept two ER docs. So that's a pretty good ratio - of a class of seven, we kept four.

And that's what we want to do. We want to keep the best ones right here taking care of the community that they've trained to take care of.

But it is very frustrating, because the way the government does graduate medical education is they want us to develop new programs in different hospitals, rather than taking the hospitals that do an excellent job already and allowing them to expand. They basically keep us capped at what we have right now.

I think Kingman could expand to have at least an internal medicine program and grow our family medicine program and even probably grow our ER. I'll tell you, the emergency medicine program is a star in the osteopathic profession. We take three or four a year. We're trying to have four every year. We have hundreds of applications for those four slots.

Family medicine has come along. Family medicine is always struggling to fill, but this year we matched all of our slots with no problem. I would say we had 50 or 60 applications for three slots. That's getting better. I'd like to see hundreds for all of them.

Mike: It shows what the need is. Arizona could do better if Arizona had more places to train. But I don't believe that the current funding scheme is going to work. I think that as an industry, as a profession we have to figure out public/private funding mechanisms to encourage people to either train in an area or move to an area in Arizona. Whether it's a town coming together or a major industry looking and saying, "There are not enough doctors in our community. How are we going to get more?" And then saying. "Why don't we partner with this institution that is training them to have a payback of time to our community when they're done training?"

They do it for medical school education a lot, but there isn't much of that in graduate medical education. So there's lots of things that we need to do.

Kelli: And I think that's one of the reasons why health care had gone the way it has without a lot of physician input. Basically, you just want to put your head down and do what you're good at, which is taking care of people. And you hope that the money is going to flow in so you can continue to do what you love.

I had my private practice in family medicine in Havasu in family medicine for 10 years. The last two years, I didn't take a paycheck myself. Well, I'm the high man and low man on the totem pole. As the owner of the business, you have to pay all of your overhead expenses, all of your employee expenses, the electric, the trash, your insurance. All of those things come first, and last is you.

I was just lucky I was married to him because he could take care of us. Because it became a very rewarding and I loved, I still love my patients, I still see them all the time. I loved my patients, but it became basically a litigious hobby, an expensive, litigious hobby that I had. And that's not why people go into medicine.

They go into medicine to make a living while taking care of patients, which hopefully they're excellent at doing. But doctors - they don't pay attention to what's happening politically. So that's how they've allowed some of this to come down on them because they just want to put their head down and work.

Miner: What about drug shortages?

Mike: We've seen that a lot. The non-availability of common use medications where you've had to substitute something else.

I believe the FDA, like all other government entities, currently, I mean we didn't see this happen that much before four years ago, I can tell you that. It didn't happen that much. I can't remember a time when they said this medication isn't available any more.

But I think that the cost of doing business in some areas has gotten so high and the regulatory burdens in some areas of pharmaceutical manufacturing has gotten so high that they choose not to make those drugs.

Miner: Can you give a few examples of what's not available?

Mike: Recently we had problems with sodium bicarbonate, which used to be kind of a mainstay in cardiac resuscitation. It was a part of the advanced cardiac life support protocols. We've had to be careful about how much we have out in the field. We've shortened the amount in the drug boxes. Which is OK. Where they used to have two they only carry one.

Kelli: There was a shortage of Regulin. We couldn't get Regulin. I mean, it's generic. It's been generic for a long time. And you couldn't get it and we use it for a lot of different things. It just wasn't there.

Mike: As far as painkillers, we kind of have an interesting area in EMS because the drug boxes per the state recommendations there is a stock level that's driven by DHS.

There are some medications that it's not helpful because you can't carry enough of a medication, like a pain medicine, for a long transport time.

In an ALS ambulance, in a paramedic staffed ambulance when River Medical does their critical care transports or their nurse transports, they have additional medications and additional availability of medications.

What DHS has had to do is allow for permissible substitutions, which they've done with some medications for seizures. Where we had to change what we were doing, which meant once you use that in the drug box, it may not be there again, and we've had that problem with Valium and Atavan at different times not being available.

There are certainly other medications out there that are commonly used that we've found have become non-available over time.

Miner: Would a lot of these be generics?

Mike: I think most of them are in the generic marketplace. So it's not that you're able to say that this generic manufacturer isn't making it right now for whatever reason so that there's this same generic manufacturer you can get it from.

Hospitals use buying centers or buying sources. So you know Kingman Regional's buying source for medication is different than Havasu Regional's buying source for medication.

So a company like River Medical that gets boxes stocked from different hospitals, they may not have something here that's still available here because of the buying sources. Basically, how much stock they have stockpiled because of their purchasing ability.

So then they all go out and fight for different medications. They go out and try to buy up more so they have it for the people they are distributing for.

Kelli: But it is frustrating when you want one thing and it's not there. There generally are alternatives that are available, but sometimes that's not on the formulary either.

Mike: It does upset practice patterns. Like lots of people we have practice patterns. There are medications you're comfortable using because you use them often and you're the most familiar with side effects and dosage and those kind of things.

We're not libraries of information inside our brains. Certainly there are doctors that have high-capacity memories. A lot of us rely on tools for that.

Miner: It's my understanding that there's not a whole lot of money in generics.

Mike: There are companies that manufacture generics as whole and make a living off of generics.

Kelli: But as the regulations on those companies go up they look at their cost/benefit, their cost of doing business. Just like I said with the emergency department.

If you're losing $9 to $40 on every patient of a certain type, how long will you maintain it? It's the same with the drug companies. If they have a good profit margin and more regulations go in ... then they're having to hire more people, then their profit margin goes down. At some point it becomes unsustainable and we risk losing drugs and we risk losing doctors. So I think we really have to look hard at that.



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Reader Comments

Posted: Sunday, March 31, 2013
Article comment by: MS Patient

In 2009 I had a 3 day treatment done through the KRMC ER. KRMC billed $2500, insurance reduced it down to $1200, and the cost to me was $250. In 2011, I had the same 3 day reatment done through the KRMC Cancer Treatment Centre. KRMC billed $1200, insurance reduced it down to $1000, and the cost to me was $200. In December of 2012, again I had the same treatment done, but this time it was at KRMC's infusion centre. KRMC billed $6000, insurance reduced it down to $4000, and the cost to me is $800. FOUR TIMES the cost for a treatment that has been around for 60 years. Oh, it's a game, but the only players are insurance companies and "non-profit" hospital, with hospitals being the aggressor.

Posted: Friday, March 15, 2013
Article comment by: Some Just Talk To Hear Themselves

The FDA began in 1906. What changes are you talking about over the last 4 years or is it just because Obama is now president?

Posted: Friday, March 15, 2013
Article comment by: Thanks for Deflating One of the Republican's Main Positions

"... if you're lucky enough to go to a state school for lower tuition, but if you go to a private school, a lot of medical schools now are private schools." And why is that? Now come on you already implied it - Bingo $$$$$. Gee, I see private medical schools like all those bucks which aren't really an option by those running public medical schools. Gee, I guess some things the government just does better. Yea, know it is also true for education all the way down to grade school.

Posted: Friday, March 15, 2013
Article comment by: My Advice to Kelli Leave Mike at Home

Most people use health insurance because they have it. A couple things come to mind. First, Mike works in the emergency room. Reading the statistics on those paying for emergency room services, I'd think he would be thrilled with the ones paying with insurance as opposed to just walking out. And I'd think for the doctors in private practices that encounter all these patients that flood into their offices just to use their health insurance could be very quickly dealt with leaving more time for "real" patience.

Yes, no doubt there are some people that do run to the doctors for every little ache. However, does Mike really believe the numbers warrant such attention. I'm sure the numbers are less than 3%.


Posted: Friday, March 15, 2013
Article comment by: One Last Question

A question I wish was asked:
How do you feel about opening more medical schools and increasing the number of doctors?


Posted: Friday, March 15, 2013
Article comment by: Latest Word Count

Mike's spoken wisdom - 1520 words

Kelli's spoken wisdom - 1174 words


Posted: Wednesday, March 13, 2013
Article comment by: just one voice

I'm so done with the Kelli & Mike Show. We now know more about their personal issues than we ever needed. Come on, Miner. This was touted as a way for us to learn more about the Affordable Care Act. Perhaps if they were able to express themselves more clearly and not allowed to ramble on in so many incomplete sentences and talking points, we might have learned something helpful.

Posted: Wednesday, March 13, 2013
Article comment by: In The Medical Field

I read alot of complaining from the two doctors in most of these articles. How about a solution? Why not help get more Nurse Practitioners in the community. This will solve many issues with family medicine as well as emergency medicine. The scholastic cost is a fraction of the cost for a doctor and we can do the same primary care job as they can and really don't complain that we get 65 to 85% of what a doctor gets paid. We are also required to keep up to date on the newest of medications and generic turn outs. Does that makes us have a bigger brain? I think not. It only makes us use that brain for something other than complaining that we don't get paid enough...wah wah wah.

Posted: Wednesday, March 13, 2013
Article comment by: Anon Anon

I've been a medical biller for several years, and while I respect your opinion, without billers you'd be broke. Maybe you know how to get paid for your services, but I haven't worked with any doctors who have. Most doctors are either too concerned with the care of their patients to worry about all of the billing elements (which isn't a bad thing) or they think they're Gods who are too good to deal with it. So believe me, you need us. And I agree that insurance is far, far more complicated than it needs to be, but let's be honest: insurance is only that complicated because Republicans like you have cultivated the idea of the glory of big business and that insurance needs to be a giant money making machine instead of something to help people pay for medical care. So if you want to start changing the system, get doctors to care about the patients instead of just the bottom line again, and get conservatives to recognize that medical care shouldn't be reserved for those who make more than $250k a year.

Posted: Tuesday, March 12, 2013
Article comment by: William W

I see several "attacks" without any substantive criticism, in previous comments. It would be useful for anyone to offer something other than personal insults, political hackery, and assumptions without foundation. If you can't do that, than you are just bloviating.

Posted: Monday, March 11, 2013
Article comment by: Frances Perkins

Too bad all these interviews were not done before the election. If being in medicine is such a burden why are you both in it? American doctors in general, are the highest paid in the western world, more than Europe, more than Canada. Why does the exact same medicine in Algodones cost one tenth to one quarter what it does in the USA. I hear a lot of problems from Mr. Ward and what solutions do you have other than the Anti-Obama talking points. And can we offer questions that are not as soft as a pillow? Why did the GOP so oppose a public, central payer OPTION, or CHOICE? I guess choice is OK only in certain circumstances, and not in reproduction freedom, or insurance choices. Maybe the Wards free market is something the rest of us don't recognize.

Posted: Monday, March 11, 2013
Article comment by: Anson's Nephew

Will this nonsense from this pair of ... well, you know ... ever end? Talk about two people being out of touch. Lord please get the next election here soon so can get Ron Gould Lite out of office.

Posted: Monday, March 11, 2013
Article comment by: Trained observer

So people have insurance just to use it? Wow! And the Wards find this upsetting? Perhaps they should get in another field where this won't be such a burden to them. And as far as how tough it was to go to medical school, support themselves etc. - they have no idea what other people go through in life. Ward does not belong in politics. More rich, priveliged whinners.

Posted: Monday, March 11, 2013
Article comment by: joker wilde

The Miner is due for an award in the category of Most Ink for a Minor right-wing Politician (and her husband) category. What a laugher!



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