How My Practice Died

Craig R. Hildreth, MD

Author’s note: in an attempt to delineate the obstacles private oncology practices face these days, the following allegory was written after the United States required all citizens to possess food insurance.

It has been a year since Congress passed the Affordable Food Act, which mandates that all Americans have adequate insurance for the purchase of groceries. Needless to say private industry, always willing to fill a new need, has answered the call-last month we filed claims with at least 12 insurance companies if you include the government plans. On the bright side, the average time our claims spend in accounts receivable is down to 38 days. That’s great except for the fact that we have to pay our wholesalers within 15 days in order to get “prompt-pay” discounts, without which we would go under faster than a cement canoe at Niagara Falls. You see, since our government sets the prices on food now we have to be very careful about what items we offer in our store. Just yesterday I lost $2 per pound on a huge order I placed right before the feds lowered the reimbursement rate on ground beef. As for coffee and chocolate-forget about it. I stopped selling those months ago when CNS (Center for Nutricare and Nutricaid Services) stopped subsidizing the cost of imported “nonessential” products.

I hate it all so much.

City Foods is the name of our store. We are no supercenter, but I also feel we’re more than a boutique grocer. I’ve owned the place for over 20 years and made my reputation the hard way by committing all of us here to compassionate, individualized service. We don’t have a million-dollar budget for advertising-word of mouth is our foundation for growth. Time was, we offered credit to our regular customers and billed them monthly.

That is all long gone now.

You might have read about the pressure independent grocers are under to sell out to the national chains. I sure as hell understand why it happens-when you can’t pay your suppliers or meet payroll, it’s all over. I honestly don’t know how long City Foods will survive under this new third party payer system. We’re trying to cooperate with all the new rules laid down by insurance companies, but if in the future you hear about the death of my store, you can blame these as the tools of its execution:

1. FMOs (food maintenance organizations). Why I agreed to join even one of these capitated plans is beyond comprehension. With an FMO I get paid a fixed rate per month per customer, but as long as they have an appointment with my store, these folks can buy as much as they want. In order to stop the bleeding I had to put in a complicated telephone menu (to discourage people from making appointments-I admit it). Not only do we now limit our store hours, but we had to hire nutritionists to counsel FMO customers about making healthy (and inexpensive) purchases.

2. Insurance company guidelines. I am grateful that the government published national guidelines on what products are preferred (which guarantees their coverage), but we’re still getting killed by companies who seem to have great difficulty acknowledging their obligation to pay for the food I sell. I am currently fighting with one company over a claim for ahi tuna-they state that they only pay for canned tuna, even though the NCFN (National Comprehensive Food Network) added ahi to their approved list 2 months ago. Then there is the matter of a $5000 order of frozen turkeys I placed last fall. The supplier’s train broke down on the way here and by the time we got the turkeys the sell-by date was nigh. Despite the fact that the manufacturer publicly guaranteed the safety of the birds, our claims were rejected-“only items purchased 3 days before the sell-by date are covered under our policy,” or so they said.

3. Precertification. You would not believe the paperwork we have to fill out when a customer needs higher priced products like balsamic vinegar, or our current nightmare-Wagyu beef. Now the insurance companies have started requiring “peer-to-peer” telephone conferences, where I have to justify my purchase to a hired “expert,” who can approve or deny my pleadings. Today I had to have a peer-to-peer in order to get one measly lobster approved. Does this explain why I see a lot of ads for fried catfish these days?

4. Payment. Remember the olden days, when customers would buy groceries with cash, check, or credit card? Now they just charge it to their food plan, which makes getting reimbursed our problem-and it is a big one. We file claims-insurance companies lose them. We refile claims-companies follow up with silence. We file complaints about the companies-and wait for South America to reattach to Africa before we get satisfaction. Our customers’ copayments continue to rise to the point where now we have to direct them to charitable foundations that will help with their costs. I had one poor guy who had a $50 copay every time he bought milk.

5. New products. Modern science has been a marvel over the past few years with the introduction of such healthy products such as cholesterol-lowering chicken, concentrated protein bars and anti-diabetes juices. Too bad some food insurance companies don’t yet consider them as “necessary and indicated,” thus I can’t offer them to my customers unless I know I am going to get reimbursed.

I’ve always told my employees that our store is like flying an airplane with a pilot and crew who will never quit, moving steadily through the sky until we run out of either fuel or atmosphere. For the first time in my career I think I see the ground moving closer-and I am worried.