Only a few more days!

Most of you will undoubtedly read the opening line and presume I am wishing happy holidays to everyone. Well, I am, however, I’m also writing in reference to the upcoming 10.1% cut in Medicare reimbursement to physicians.

You may be wondering why this is a big deal. Well for one, it will make it harder and harder for Family Physicians, such as myself to continue providing medical care to Medicare recipients. Why? Well, over the past several years, reimbursement for physician services, specifically to family physicians, has steadily declined. As the cost of running an office rises, ie heat, electricity, staff, equipment, et al, rises, the difference between income and expenses broadens and is soon reaching a point where reimbursement does not cover the cost of providing the care.

I would kindly ask everyone (if anyone is actually reading this blog) to contact Senators Snowe and Collins to stop the pending cuts.

To quote the Bartles and Jaymes commercial, thanks for your support.

Planned Medicare Cuts Weigh On Primary Care

From the Wall Street Journal (http://online.wsj.com/article/SB119732809319620055.html?mod=moj_columnis)

Planned Medicare Cuts Weigh on Primary Care
December 11, 2007
While presidential candidates are beating each other up about their plans for the uninsured, they've taken their eye off another big issue. Access to primary care for millions of people enrolled in Medicare is in peril.

As each new year approaches, doctors across the country brace for cuts in payments from Medicare. Unless there's a reprieve soon, Medicare will reduce payments to doctors by an average of 10.1% starting Jan. 1. (See the details here). Last year a planned reduction of 5% was averted by Congress at the last minute and payments stayed about flat.

Another deal remains possible. But the constant threat of decreases and the absence of increases in recent years are leading doctors to re-think their commitment to caring for Medicare patients. The question is becoming acute for primary care doctors, who are faring worse than those in other specialties.

To see why, it's worth a quick look to see how Medicare calculates how much to pay a doctor for care. There's a complex formula, but one of the keys is something called a work relative value unit that Medicare assigns to doctors' activities based on their specialties. An hour of brain surgery is valued more highly than an hour of general medical care.

Where a doctor practices also influences the payment calculation. Rural health clinics like mine operate under a special government program and will likely get a small cost of living adjustment next year.

In the end, Medicare multiplies a total relative value unit, factoring in various adjustments, by a payment benchmark to come up with fees for physician services. (For more, see this summary from the American Medical Association.)

The formula means that there are two ways for doctors to gain or lose under Medicare. The benchmark can be adjusted up or down, affecting all doctors. And the modifiers assigned to each specialty can be increased or decreased. Adjustment of the financial weight given to specialties is generally a zero-sum game and that pits one group of doctors against another in the lobbying wars.

Family medicine has been a loser, with its modifier decreasing since 2001. My medical school classmates who opted for anesthesiology are in line for a 4% increase next year. Coupling the lower payment factor for family medicine with the planned 10.1% drop in the benchmark for Medicare equals a big hit to primary care.

The Medicare crunch has been a big topic of conversation in an online discussion group on practice management run by the American Academy of Family Physicians. I'm a member and have found the chatter a little depressing.

As you might imagine, some doctors predict more grumbling and then eventual acceptance of what would amount to a salary cut for seeing Medicare patients.

Some expect to see more Medicare patients to make up for cuts with higher volume. Dr. Shane Avery, a solo practitioner in Scottsburg, Ind., will ask patients to come to the office for everything, no matter how small. Medicare doesn't pay enough to cover his overhead for the range of services he provides outside of an office visit, such as phone consultations.

Dr. Kathy Saradarian of Branchville, N.J., predicts Medicare cuts will prompt doctors to see patients more often but spend less time during each visit. But even that adjustment may not be enough. In her area of New Jersey, insurance payments are so low that Medicare is her best payer. Any cuts will come right off her bottom line. "They think we can make up the losses in other ways, but we can't," she says. "It is disheartening."

Others are considering dropping out of Medicare altogether. Dr. Marie Steinmetz, of Alexandria, Va., stopped taking Medicare six years ago because the payments didn't cover her expenses. Her practice offers traditional medical care with complementary and alternative medicine that insurance generally doesn't pay for anyway.

A family doctor in rural California named Deborah Sutcliffe stopped taking new Medicare patients two years ago. Now she's thinking about requiring her remaining Medicare patients to pay her directly rather than taking her fee via Medicare. If she goes this route, she's allowed to charge a slightly higher price. Medicare sends partial reimbursement for the office visit to the patient, and the patient pays the difference. This approach usually results in more overhead for a practice, but the total collections for the same sorts of visits can be 15% higher.

Elizabeth Pector, a family practitioner in Naperville, Ill., worries most about the effect a Medicare cut could have on other insurers. Many tie their reimbursement to Medicare. If the private sector rates drop 10%, too, her practice could be in big trouble. She worries about the health and options for our seniors, but finds herself worrying more urgently about the health of her practice.

While everyone's talking about how to expand health care for the uninsured, I think it's time to fix the Medicare system that's leading many doctors who tend to the basic health-care needs of the elderly to reconsider the proposition.

Message for the New Year

Received this via e-mail and although I can’t validate it, the message has been attributed to George Carlin. Regardless of it’s original source, the message is one that I certainly took to heart and one that I would encourage off of us to think about from time to time.


A Message by George Carlin:

The paradox of our time in history is that we have taller buildings but
shorter tempers, wider Freeways , but narrower viewpoints. We spend
more, but have less, we buy more, but enjoy less. We have bigger houses
and smaller families, more conveniences, but less time. We have more
degrees but less sense, more knowledge, but less judgment, more experts,
yet more problems, more medicine, but less wellness.

We drink too much, smoke too much, spend too recklessly, laugh too
little, drive too fast, get too angry, stay up too late, get up too
tired, read too little, watch TV too much, and pray too seldom.

We have multiplied our possessions, but reduced our values. We talk too
much, love too seldom, and hate too often.

We've learned how to make a living, but not a life. We've added years to
life not life to years. We've been all the way to the moon and back, but
have trouble crossing the street to meet a new neighbor. We conqu e red
outer space but not inner space. We've done larger things, but not
better things.

We've cleaned up the air, but polluted the soul. We've conquered the
atom, but not our prejudice. We write more, but learn less. We plan
more, but accomplish less. We've learned to rush, but not to wait. We
build more computers to hold more information, to produce more copies
than ever, but we communicate less and less.

These are the times of fast foods and slow digestion, big men and small
character, steep profits and shallow relationships. These are the days
of two incomes but more divorce, fancier houses, but broken homes. These
are days of quick trips, disposable diapers, throwaway morality, one
night stands, overweight bodies, and pills that do everything from
cheer, to quiet, to kill. It is a time when there is much in the
showroom window and nothing in the stockroom. A time when technology can
bring this letter t o you, and a time when you can choose either to
share this insight, or to just hit delete...

Remember; spend some time with your loved ones, because they are not
going to be around forever.

Remember, say a kind word to someone who looks up to you in awe, because
that little person soon will grow up and leave your side.

Remember, to give a warm hug to the one next to you, because that is the
only treasure you can give with your heart and it doesn't cost a cent.

Remember, to say, "I love you" to your partner and your loved ones, but
most of all mean it. A kiss and an embrace will mend hurt when it comes
from deep inside of you.

Remember to hold hands and cherish the moment for someday that person
will not be there again.

Give time to love, give time to speak! And give time to share the
precious thoughts in your mind.

AND ALWAYS REMEMBER:

Life is not measured by the number of breaths we take, but by the
moments that take our breath away.

If you don't send this to at least 8 people....Who cares?

George Carlin 


Not just another Doc on the block

http://www.themaineedge.com/content/5473/Not_just_another_Doc_on_the_block/

Little free publicity never hurts

please tell me someone is joking

Caught this in my RSS feeder and, although I’ve seen things like this before, I continue to be amazed and baffled with out criminal justice system.

http://www.foxnews.com/story/0,2933,311748,00.html

I mean really, I, an innocent taxpayor who hasn’t committed any crime, don’t get to watch Monday Night Football. So why it that my/our hardearned money should be spent even entertainer such a thought as this. I have a better idea....make prison something you want to stay out of!

cows, constitution and commandments

I have no idea where this list originated, but when I received it via e-mail, I just couldn’t help but post it.

Three Things to Ponder:
     1. Cows
     2. The Constitution
     3. The Ten Commandments
 
C O W S
 
Is it just me, or does anyone else find it amazing that during the mad cow epidemic our government could track a single cow, born in Canada almost three years ago, right to the stall where she slept in the state of Washington? And, they tracked her calves to their stalls. But they are unable to locate 11 million illegal aliens wandering around our country. Maybe we should give each of them a cow.

T H E    C O N S T I T U T I O N
They keep talking about drafting a Constitution for Iraq. Why don't we just give them ours? It was written by a lot of really smart guys, it has worked for over 200 years, and we're not using it anymore.

T H E   1 0    C O M M A N D M E N T S
The real reason that we can't have the Ten Commandments posted in a courthouse is this:

You cannot post "Thou Shalt Not Steal," "Thou Shalt Not Commit Adultery," and "Thou Shall Not Lie" in a building full of lawyers, judges and politicians...It creates a hostile work environment.

Have you seen my homework?

Having some time to think over the recent decision by the King Middle School school board regarding the provision of oral contraceptives to middle school children, I have to wonder how wise of a decision this actually is.

Having a 13 year-old son of my own, I am often humored by his seeming lack of forethought when it comes to:
-getting homework assignments done in a timely fashion as well as remembering to bring in the homework assignment to school (how many of us have gotten frantic calls pleading for us to bring in something our kids forgot???)
-recognizing the need to notify my wife and I about school events with more than a 15 minute notice before such an event (such as...“oh, by the way, I have a concert tonight”)
-recalling an early morning commitment for an extracurricular activity (“what time do you need to be at school?”...“now”...)

Now, don’t get me wrong, for the most part, both of my boys do an excellent job with keeping my wife and I informed of their various school activities, but I’m sure we aren’t the only parents who get such frantic notices....am I right?

Outside of the obvious health concerns with providing immature children potent medications, it doesn’t seem like a very wise decision to pass on the responsibility of a daily medication to a population who has difficulty remembering where they put their clothes!?!

Along with this, the school board at King Middle School is advocating a stance which would place an adult responsibility on a child. Yeck, I have a hard time with adult responsibility!

Thoughts?

Learning along the way

Date: August 30, 2007 12:22 AM
Topic: Learning along the way

As many of you know, come October 1, 2007, I'll be heading into the
wonderful world of "private practice". As someone who prided himself
in constantly being educated in the areas of practice management,
billing and coding, etc, it's actually been a very frustrating
experience.

Not frustrating from a lack of understanding, but rather from the
fact that I have ZERO negotiating power. Third party payors are
holding nearly all the marbles. Now, this is certainly not a posting
to advocate for a single-payor healthcare system, which would be a
complete disaster, but rather a deeper realization of how bass-
ackwards the "system" is.

For example, typically when you "contract" with someone to perform a
job, the involved parties agree on some basic tenets...I'd like to
have the project completed by such-and-such a time and I'd like it
done within certain parameters; sky blue, not navy blue; all 4 walls
rather than just 3. I'm not going to dictate to you how you actually
paint a wall, but rather judge the work process by the end result.
This is not the case with the "practice" of medicine. Over the next
few blog postings, I'll be sharing some seemingly odd discrepancies
in the professional agreements or "contracts" physicians have with
payors (ie, insurance carries), but let me begin with a payor near
and dear to my heart (cough - cough)....Medicare.

About 2 months ago, and knowing I would be moving into private
practice, I contacted our lovely government-run insurance carrier.
You know one of the ones which we as tax payers dump loads of money
into? I contacted them seemingly far enough in advance to prevent
any delay in the "credentialling" process and to ensure that all of
my contact information, etc was updated.

As I would be forming a group practice, I would need to apply for a
Group NPI (national provider identification) on top of my already
existing personal NPI, UPIN (universal physician identification
number) and Medicare ID number. Now one would think that a single ID
# would suffice. "We" were told that at some point it
"will" (although everyone was supposed to adopt this new-and-improved
system in May, 2007) be adopted as THE number physicians and
provider are assigned and all previous numbers would evaporate.

So, like a good little compliant physician, I complete the...hmmm...5
forms??? and submitted then, as directed and with enough advance
notice that by opening day everything would be in order.

This past Monday I received notification that I had submitted my
paperwork "too soon" and would have to resubmit every wonderful piece
of paperwork within the "mandated" 30-day window. Now here's one of
the catches...you can't submit it until within 30-days of your new
office, but Medicare has up to 120 days to review and if everything
is in order, stamp the necessary paperwork with the almighty
"approved" designation.

When I questioned the representative about this because frankly it
doesn't make sense that I had to submit the documents within 30 days,
but they can take an additional 90 to "review things", I was, in so
many words, told....silly Doctor, Trix are for kids!

So, my options at this point include:
1. crap load of prayer that everything will be in order
2. float the gov't a loan by seeing Medicare patients over the next
couple of months and provided all of my documents are in order,
submit the claims afterward. So, if I see half a dozen Medicare
patients.....let's do the math....heck, it's too late for math, but
the long and short of it is that I'll be dutifully providing medical
services which may or may not be reimbursed in a timely fashion and
not until after it's been proven that I am a physician and in fact,
do care for Medicare patients.

An additional frustration is that this is now the 3rd time I've had
to go through this process in the past 5 years. I feel fortunate
because I have way too much time on my hands and I couldn't be more
thankful that the gov't gives me the opportunity to keep myself
occupied with the revolving door of credentialling.

Now, of course, it is now 48 hours + since receiving the notification
above and although I was assured that "I'll call you back", I've not
heard hide nor tail of the representative (or stand-in) that I spoke
with. Patients is a virtue, but really.....

So, we'll see what happens over the course of the next day or so and
hopefully if I don't get a response by Friday, see if anyone actually
remembers the on-going conversations I've had this week and last

Stay tuned........

My Journal

My Journal

Date: January 13, 2005 4:52 PM
Topic: Thoughts on Convocation

Well, having recently returned from the AAO Convocation, I must say
that overall, I think the Convocation went well. The major downside
to the entire event is that the "environment"

Date: September 17, 2005 9:35 AM
Topic: Future of Family Medicine

So, where is the specialty of Family Medicine headed? It seems that
at every corner, Family Physicians are becoming less and less
prevalent. Over time, less and less Family Docs did OB, now fewer are
doing in-patient work. How is it that our Society/College/National
organizations have allowed this parsing to take place? And, more
importantly, where will "Family Medicine" be in another year?

I recall a comment my GP (that's what the term was then) made to me
at my sister's wedding in reference to the Hospitalist movement; "why
is it that when a patient is the sickest and needs their Doctor the
most, their Doctor abandons them to someone else?". This comment
continues to stick with me whenever I hear of another Family Doc
"gives up" their hospital work.

Comments?

Date: December 8, 2005 5:12 PM
Topic: Can't quite believe it

Can't quite believe this article, but seems to be "open hunting
season" on Physicians (ie, more and more articles like this coming out)

http://www.msnbc.msn.com/id/10349325/

See, the problem I have with this article isn't that I support this
particular Physician's "fee", but moreso that the author failed to
comment on the global "shafting" Physicians are taking. Let me share
a few examples....

1. Insurance company's frequent changing of the rules, altering
physician billing, undercutting physician reimbursement
2. Dropping Medicare reimbursement to Physicians, in particular,
Family Physicians
3. Pending "pay-for-performance" requirements for reimbursement.
While I agree with being "paid" to provide excellent medical care,
why is it that I should be "punished" (ie not reimbursed) if a
patient refuses the recommended medical care?
4. Decreasing graduate medical education funds for the training of
new physicians
5. "bundling" by insurance companies, that is refusing to pay for
more than one service on the same day
6. the list continues

Comments?

Date: June 26, 2006 11:29 AM
Topic: Sorry, no payment here

Date: July 26, 2006 12:52 PM
Topic: Sorry, no payment
So, the Government decides that Physicians and Health Care
Organizations will just have to do without
September is payment free
Interesting that the Government is able to make this unilateral
decision when, if the situation were reveresed, they certainly
wouldn't feel the same way (can I skip a few days worth of bills?)
Date: August 29, 2006 4:38 PM
Topic: Call me paranoid
I'll admit that I can be a bit on the paranoid site when it comes to
the integration of technology in our lives, but this (VeriChip Sells
First Baby Protection System) really got my attention.
I remember, several years ago (in fact little over a decade) reading
a snippet from a purported conspiracy newsletter than made mention of
this technology and the eventual integration into our daily lives.
Now, although this article paints the picture of safety, I can't help
but wonder what devious plans the great "Big Brother" powers may have
for technology such as this.
Will there come a day when such implanted technology is required?
What is there to stop this eventuality?
Blogged with Flock

Date: September 2, 2006 11:52 AM
Topic: "Primary Care Physician"
I do not practice "Family Practice" nor do I see patients in a
"clinic". For that matter, I am not a "Primary Care Provider", but
rather I provide medical care to a wide range of ages; birth to
death, unfortunately taxes in between. So what is the best title to
have? Am I a "GP" or an "FP"?
Rather than words, it's actions which define who someone is...take
for example the thousands, likely millions of people who wear gold
crosses around their neck, yet their actions do not represent the
tenets of "Christianity". Or perhaps, the "Republican" who claims to
be a conservative, yet abhors "conservative values". Perhaps the
"Liberal" who preaches tolerance, yet won't let citizens express
philosophical/political/religious views which differ from their own.
One of the problems in "Family Medicine" is that this specialty
(which historically served as the foundation for nearly all other
specialties) is allowing itself to be labeled by those who know very
little about what it means to provide the "full spectrum of care".
Take for example the following "definitions" for "Family Medicine"
from a variety of specialites...
-Pediatrics: something other than kids, unless of course the young
lady begins her menstrual cycle when she should, of course, see a
gynecologist
-Internal Medicine: obviously nothing overly complicated as they
don't have the expertise in managing chronic disease that our
specialty training offers
-Obstetrics: something other the pregnant women who should only see
our specialty, that is unless I hire a CNM whom I have given
clearance (c'mon CNM's fight back!)
-Gastroenterologists: just don't do colonoscopies or endoscopies.
These are very trick procedures...what you've done 1000? Well, when
you reach 2000, I'll reconsider
-Cardiology: just don't read EKG's
-Hospitalists: yes, when your patients are the sickest and need to be
admitted, you should really turn them over to us, after all, it's a
financial loss for your office if you "have to" care for your own
patients
Shall I go on?
The specialty of "Family Medicine" needs to grow a big set of
cajones. We need to revitalize the specialty and reinvigorate the
masses. We need to stop allowing other forces (hospitals, insurance
carriers, specialites, media, impotent colleagues) to define who we are.

Date: July 6, 2006 6:42 PM
Topic: Beginning of a new year

So, it's about this time of the year when the hospitals are flooded
with new resident physicians, affectionately called "interns".
Fortunately for us, we have a great new group of vivacious and
energetic resident physicians who are now in the midst of the first
real week of residency (okay, week #2, but who's counting the typical
orientation material anyway?)

This is also the time of year when graduating residens enter the vast
world of attending-dom. The buck stops with them now.

As each enters their own phase of their new lives, what should they
look forward to?

Well, gone are the completely endless nights of call and >24 hours
per shift (I had the dubious privilege of being the last class to
experience this wonderous opportunity), however, our "new" physicians
will begin to experienced the glorious world of prior authorizations,
preferred medication list

Date: July 26, 2006 12:52 PM
Topic: Sorry, no payment

So, the Government decides that Physicians and Health Care
Organizations will just have to do without

September is payment free

Interesting that the Government is able to make this unilateral
decision when, if the situation were reveresed, they certainly
wouldn't feel the same way (can I skip a few days worth of bills?)

Date: August 29, 2006 4:38 PM
Topic: Call me paranoid

I'll admit that I can be a bit on the paranoid site when it comes to
the integration of technology in our lives, but this (VeriChip Sells
First Baby Protection System) really got my attention.

I remember, several years ago (in fact little over a decade) reading
a snippet from a purported conspiracy newsletter than made mention of
this technology and the eventual integration into our daily lives.
Now, although this article paints the picture of safety, I can't help
but wonder what devious plans the great "Big Brother" powers may have
for technology such as this.

Will there come a day when such implanted technology is required?
What is there to stop this eventuality?
Blogged with Flock

Date: September 2, 2006 11:52 AM
Topic: "Primary Care Physician"

I do not practice "Family Practice" nor do I see patients in a
"clinic". For that matter, I am not a "Primary Care Provider", but
rather I provide medical care to a wide range of ages; birth to
death, unfortunately taxes in between. So what is the best title to
have? Am I a "GP" or an "FP"?

Rather than words, it's actions which define who someone is...take
for example the thousands, likely millions of people who wear gold
crosses around their neck, yet their actions do not represent the
tenets of "Christianity". Or perhaps, the "Republican" who claims to
be a conservative, yet abhors "conservative values". Perhaps the
"Liberal" who preaches tolerance, yet won't let citizens express
philosophical/political/religious views which differ from their own.

One of the problems in "Family Medicine" is that this specialty
(which historically served as the foundation for nearly all other
specialties) is allowing itself to be labeled by those who know very
little about what it means to provide the "full spectrum of care".

Take for example the following "definitions" for "Family Medicine"
from a variety of specialites...
-Pediatrics: something other than kids, unless of course the young
lady begins her menstrual cycle when she should, of course, see a
gynecologist
-Internal Medicine: obviously nothing overly complicated as they
don't have the expertise in managing chronic disease that our
specialty training offers
-Obstetrics: something other the pregnant women who should only see
our specialty, that is unless I hire a CNM whom I have given
clearance (c'mon CNM's fight back!)
-Gastroenterologists: just don't do colonoscopies or endoscopies.
These are very trick procedures...what you've done 1000? Well, when
you reach 2000, I'll reconsider
-Cardiology: just don't read EKG's
-Hospitalists: yes, when your patients are the sickest and need to be
admitted, you should really turn them over to us, after all, it's a
financial loss for your office if you "have to" care for your own
patients

Shall I go on?

The specialty of "Family Medicine" needs to grow a big set of
cajones. We need to revitalize the specialty and reinvigorate the
masses. We need to stop allowing other forces (hospitals, insurance
carriers, specialites, media, impotent colleagues) to define who we are.

Date: August 30, 2007 12:22 AM
Topic: Learning along the way

As many of you know, come October 1, 2007, I'll be heading into the
wonderful world of "private practice". As someone who prided himself
in constantly being educated in the areas of practice management,
billing and coding, etc, it's actually been a very frustrating
experience.

Not frustrating from a lack of understanding, but rather from the
fact that I have ZERO negotiating power. Third party payors are
holding nearly all the marbles. Now, this is certainly not a posting
to advocate for a single-payor healthcare system, which would be a
complete disaster, but rather a deeper realization of how bass-
ackwards the "system" is.

For example, typically when you "contract" with someone to perform a
job, the involved parties agree on some basic tenets...I'd like to
have the project completed by such-and-such a time and I'd like it
done within certain parameters; sky blue, not navy blue; all 4 walls
rather than just 3. I'm not going to dictate to you how you actually
paint a wall, but rather judge the work process by the end result.
This is not the case with the "practice" of medicine. Over the next
few blog postings, I'll be sharing some seemingly odd discrepancies
in the professional agreements or "contracts" physicians have with
payors (ie, insurance carries), but let me begin with a payor near
and dear to my heart (cough - cough)....Medicare.

About 2 months ago, and knowing I would be moving into private
practice, I contacted our lovely government-run insurance carrier.
You know one of the ones which we as tax payers dump loads of money
into? I contacted them seemingly far enough in advance to prevent
any delay in the "credentialling" process and to ensure that all of
my contact information, etc was updated.

As I would be forming a group practice, I would need to apply for a
Group NPI (national provider identification) on top of my already
existing personal NPI, UPIN (universal physician identification
number) and Medicare ID number. Now one would think that a single ID
# would suffice. "We" were told that at some point it
"will" (although everyone was supposed to adopt this new-and-improved
system in May, 2007) be adopted as THE number physicians and
provider are assigned and all previous numbers would evaporate.

So, like a good little compliant physician, I complete the...hmmm...5
forms??? and submitted then, as directed and with enough advance
notice that by opening day everything would be in order.

This past Monday I received notification that I had submitted my
paperwork "too soon" and would have to resubmit every wonderful piece
of paperwork within the "mandated" 30-day window. Now here's one of
the catches...you can't submit it until within 30-days of your new
office, but Medicare has up to 120 days to review and if everything
is in order, stamp the necessary paperwork with the almighty
"approved" designation.

When I questioned the representative about this because frankly it
doesn't make sense that I had to submit the documents within 30 days,
but they can take an additional 90 to "review things", I was, in so
many words, told....silly Doctor, Trix are for kids!

So, my options at this point include:
1. crap load of prayer that everything will be in order
2. float the gov't a loan by seeing Medicare patients over the next
couple of months and provided all of my documents are in order,
submit the claims afterward. So, if I see half a dozen Medicare
patients.....let's do the math....heck, it's too late for math, but
the long and short of it is that I'll be dutifully providing medical
services which may or may not be reimbursed in a timely fashion and
not until after it's been proven that I am a physician and in fact,
do care for Medicare patients.

An additional frustration is that this is now the 3rd time I've had
to go through this process in the past 5 years. I feel fortunate
because I have way too much time on my hands and I couldn't be more
thankful that the gov't gives me the opportunity to keep myself
occupied with the revolving door of credentialling.

Now, of course, it is now 48 hours + since receiving the notification
above and although I was assured that "I'll call you back", I've not
heard hide nor tail of the representative (or stand-in) that I spoke
with. Patients is a virtue, but really.....

So, we'll see what happens over the course of the next day or so and
hopefully if I don't get a response by Friday, see if anyone actually
remembers the on-going conversations I've had this week and last

Stay tuned........

MacJournal

Date: January 13, 2005 4:52 PM
Topic: Thoughts on Convocation

Well, having recently returned from the AAO Convocation, I must say
that overall, I think the Convocation went well. The major downside
to the entire event is that the "environment"

Date: September 17, 2005 9:35 AM
Topic: Future of Family Medicine

So, where is the specialty of Family Medicine headed? It seems that
at every corner, Family Physicians are becoming less and less
prevalent. Over time, less and less Family Docs did OB, now fewer are
doing in-patient work. How is it that our Society/College/National
organizations have allowed this parsing to take place? And, more
importantly, where will "Family Medicine" be in another year?

I recall a comment my GP (that's what the term was then) made to me
at my sister's wedding in reference to the Hospitalist movement; "why
is it that when a patient is the sickest and needs their Doctor the
most, their Doctor abandons them to someone else?". This comment
continues to stick with me whenever I hear of another Family Doc
"gives up" their hospital work.

Comments?

Date: December 8, 2005 5:12 PM
Topic: Can't quite believe it

Can't quite believe this article, but seems to be "open hunting
season" on Physicians (ie, more and more articles like this coming out)

http://www.msnbc.msn.com/id/10349325/

See, the problem I have with this article isn't that I support this
particular Physician's "fee", but moreso that the author failed to
comment on the global "shafting" Physicians are taking. Let me share
a few examples....

1. Insurance company's frequent changing of the rules, altering
physician billing, undercutting physician reimbursement
2. Dropping Medicare reimbursement to Physicians, in particular,
Family Physicians
3. Pending "pay-for-performance" requirements for reimbursement.
While I agree with being "paid" to provide excellent medical care,
why is it that I should be "punished" (ie not reimbursed) if a
patient refuses the recommended medical care?
4. Decreasing graduate medical education funds for the training of
new physicians
5. "bundling" by insurance companies, that is refusing to pay for
more than one service on the same day
6. the list continues

Comments?

Date: July 6, 2006 6:42 PM
Topic: Beginning of a new year

So, it's about this time of the year when the hospitals are flooded
with new resident physicians, affectionately called "interns".
Fortunately for us, we have a great new group of vivacious and
energetic resident physicians who are now in the midst of the first
real week of residency (okay, week #2, but who's counting the typical
orientation material anyway?)

This is also the time of year when graduating residens enter the vast
world of attending-dom. The buck stops with them now.

As each enters their own phase of their new lives, what should they
look forward to?

Well, gone are the completely endless nights of call and >24 hours
per shift (I had the dubious privilege of being the last class to
experience this wonderous opportunity), however, our "new" physicians
will begin to experienced the glorious world of prior authorizations,
preferred medication list

Date: July 26, 2006 12:52 PM
Topic: Sorry, no payment

So, the Government decides that Physicians and Health Care
Organizations will just have to do without

September is payment free

Interesting that the Government is able to make this unilateral
decision when, if the situation were reveresed, they certainly
wouldn't feel the same way (can I skip a few days worth of bills?)

Date: August 29, 2006 4:38 PM
Topic: Call me paranoid

I'll admit that I can be a bit on the paranoid site when it comes to
the integration of technology in our lives, but this (VeriChip Sells
First Baby Protection System) really got my attention.

I remember, several years ago (in fact little over a decade) reading
a snippet from a purported conspiracy newsletter than made mention of
this technology and the eventual integration into our daily lives.
Now, although this article paints the picture of safety, I can't help
but wonder what devious plans the great "Big Brother" powers may have
for technology such as this.

Will there come a day when such implanted technology is required?
What is there to stop this eventuality?
Blogged with Flock

Date: September 2, 2006 11:52 AM
Topic: "Primary Care Physician"

I do not practice "Family Practice" nor do I see patients in a
"clinic". For that matter, I am not a "Primary Care Provider", but
rather I provide medical care to a wide range of ages; birth to
death, unfortunately taxes in between. So what is the best title to
have? Am I a "GP" or an "FP"?

Rather than words, it's actions which define who someone is...take
for example the thousands, likely millions of people who wear gold
crosses around their neck, yet their actions do not represent the
tenets of "Christianity". Or perhaps, the "Republican" who claims to
be a conservative, yet abhors "conservative values". Perhaps the
"Liberal" who preaches tolerance, yet won't let citizens express
philosophical/political/religious views which differ from their own.

One of the problems in "Family Medicine" is that this specialty
(which historically served as the foundation for nearly all other
specialties) is allowing itself to be labeled by those who know very
little about what it means to provide the "full spectrum of care".

Take for example the following "definitions" for "Family Medicine"
from a variety of specialites...
-Pediatrics: something other than kids, unless of course the young
lady begins her menstrual cycle when she should, of course, see a
gynecologist
-Internal Medicine: obviously nothing overly complicated as they
don't have the expertise in managing chronic disease that our
specialty training offers
-Obstetrics: something other the pregnant women who should only see
our specialty, that is unless I hire a CNM whom I have given
clearance (c'mon CNM's fight back!)
-Gastroenterologists: just don't do colonoscopies or endoscopies.
These are very trick procedures...what you've done 1000? Well, when
you reach 2000, I'll reconsider
-Cardiology: just don't read EKG's
-Hospitalists: yes, when your patients are the sickest and need to be
admitted, you should really turn them over to us, after all, it's a
financial loss for your office if you "have to" care for your own
patients

Shall I go on?

The specialty of "Family Medicine" needs to grow a big set of
cajones. We need to revitalize the specialty and reinvigorate the
masses. We need to stop allowing other forces (hospitals, insurance
carriers, specialites, media, impotent colleagues) to define who we are.

Date: August 29, 2007 11:29 AM
Topic: Sorry, no payment here

Date: July 26, 2006 12:52 PM
Topic: Sorry, no payment
So, the Government decides that Physicians and Health Care
Organizations will just have to do without
September is payment free
Interesting that the Government is able to make this unilateral
decision when, if the situation were reveresed, they certainly
wouldn't feel the same way (can I skip a few days worth of bills?)
Date: August 29, 2006 4:38 PM
Topic: Call me paranoid
I'll admit that I can be a bit on the paranoid site when it comes to
the integration of technology in our lives, but this (VeriChip Sells
First Baby Protection System) really got my attention.
I remember, several years ago (in fact little over a decade) reading
a snippet from a purported conspiracy newsletter than made mention of
this technology and the eventual integration into our daily lives.
Now, although this article paints the picture of safety, I can't help
but wonder what devious plans the great "Big Brother" powers may have
for technology such as this.
Will there come a day when such implanted technology is required?
What is there to stop this eventuality?
Blogged with Flock

Date: September 2, 2006 11:52 AM
Topic: "Primary Care Physician"
I do not practice "Family Practice" nor do I see patients in a
"clinic". For that matter, I am not a "Primary Care Provider", but
rather I provide medical care to a wide range of ages; birth to
death, unfortunately taxes in between. So what is the best title to
have? Am I a "GP" or an "FP"?
Rather than words, it's actions which define who someone is...take
for example the thousands, likely millions of people who wear gold
crosses around their neck, yet their actions do not represent the
tenets of "Christianity". Or perhaps, the "Republican" who claims to
be a conservative, yet abhors "conservative values". Perhaps the
"Liberal" who preaches tolerance, yet won't let citizens express
philosophical/political/religious views which differ from their own.
One of the problems in "Family Medicine" is that this specialty
(which historically served as the foundation for nearly all other
specialties) is allowing itself to be labeled by those who know very
little about what it means to provide the "full spectrum of care".
Take for example the following "definitions" for "Family Medicine"
from a variety of specialites...
-Pediatrics: something other than kids, unless of course the young
lady begins her menstrual cycle when she should, of course, see a
gynecologist
-Internal Medicine: obviously nothing overly complicated as they
don't have the expertise in managing chronic disease that our
specialty training offers
-Obstetrics: something other the pregnant women who should only see
our specialty, that is unless I hire a CNM whom I have given
clearance (c'mon CNM's fight back!)
-Gastroenterologists: just don't do colonoscopies or endoscopies.
These are very trick procedures...what you've done 1000? Well, when
you reach 2000, I'll reconsider
-Cardiology: just don't read EKG's
-Hospitalists: yes, when your patients are the sickest and need to be
admitted, you should really turn them over to us, after all, it's a
financial loss for your office if you "have to" care for your own
patients
Shall I go on?
The specialty of "Family Medicine" needs to grow a big set of
cajones. We need to revitalize the specialty and reinvigorate the
masses. We need to stop allowing other forces (hospitals, insurance
carriers, specialites, media, impotent colleagues) to define who we are.

Date: August 30, 2007 12:22 AM
Topic: Learning along the way

As many of you know, come October 1, 2007, I'll be heading into the
wonderful world of "private practice". As someone who prided himself
in constantly being educated in the areas of practice management,
billing and coding, etc, it's actually been a very frustrating
experience.

Not frustrating from a lack of understanding, but rather from the
fact that I have ZERO negotiating power. Third party payors are
holding nearly all the marbles. Now, this is certainly not a posting
to advocate for a single-payor healthcare system, which would be a
complete disaster, but rather a deeper realization of how bass-
ackwards the "system" is.

For example, typically when you "contract" with someone to perform a
job, the involved parties agree on some basic tenets...I'd like to
have the project completed by such-and-such a time and I'd like it
done within certain parameters; sky blue, not navy blue; all 4 walls
rather than just 3. I'm not going to dictate to you how you actually
paint a wall, but rather judge the work process by the end result.
This is not the case with the "practice" of medicine. Over the next
few blog postings, I'll be sharing some seemingly odd discrepancies
in the professional agreements or "contracts" physicians have with
payors (ie, insurance carries), but let me begin with a payor near
and dear to my heart (cough - cough)....Medicare.

About 2 months ago, and knowing I would be moving into private
practice, I contacted our lovely government-run insurance carrier.
You know one of the ones which we as tax payers dump loads of money
into? I contacted them seemingly far enough in advance to prevent
any delay in the "credentialling" process and to ensure that all of
my contact information, etc was updated.

As I would be forming a group practice, I would need to apply for a
Group NPI (national provider identification) on top of my already
existing personal NPI, UPIN (universal physician identification
number) and Medicare ID number. Now one would think that a single ID
# would suffice. "We" were told that at some point it
"will" (although everyone was supposed to adopt this new-and-improved
system in May, 2007) be adopted as THE number physicians and
provider are assigned and all previous numbers would evaporate.

So, like a good little compliant physician, I complete the...hmmm...5
forms??? and submitted then, as directed and with enough advance
notice that by opening day everything would be in order.

This past Monday I received notification that I had submitted my
paperwork "too soon" and would have to resubmit every wonderful piece
of paperwork within the "mandated" 30-day window. Now here's one of
the catches...you can't submit it until within 30-days of your new
office, but Medicare has up to 120 days to review and if everything
is in order, stamp the necessary paperwork with the almighty
"approved" designation.

When I questioned the representative about this because frankly it
doesn't make sense that I had to submit the documents within 30 days,
but they can take an additional 90 to "review things", I was, in so
many words, told....silly Doctor, Trix are for kids!

So, my options at this point include:
1. crap load of prayer that everything will be in order
2. float the gov't a loan by seeing Medicare patients over the next
couple of months and provided all of my documents are in order,
submit the claims afterward. So, if I see half a dozen Medicare
patients.....let's do the math....heck, it's too late for math, but
the long and short of it is that I'll be dutifully providing medical
services which may or may not be reimbursed in a timely fashion and
not until after it's been proven that I am a physician and in fact,
do care for Medicare patients.

An additional frustration is that this is now the 3rd time I've had
to go through this process in the past 5 years. I feel fortunate
because I have way too much time on my hands and I couldn't be more
thankful that the gov't gives me the opportunity to keep myself
occupied with the revolving door of credentialling.

Now, of course, it is now 48 hours + since receiving the notification
above and although I was assured that "I'll call you back", I've not
heard hide nor tail of the representative (or stand-in) that I spoke
with. Patients is a virtue, but really.....

So, we'll see what happens over the course of the next day or so and
hopefully if I don't get a response by Friday, see if anyone actually
remembers the on-going conversations I've had this week and last

Stay tuned........

MacJournal

Date: January 13, 2005 4:52 PM
Topic: Thoughts on Convocation

Well, having recently returned from the AAO Convocation, I must say
that overall, I think the Convocation went well. The major downside
to the entire event is that the "environment"

Date: September 17, 2005 9:35 AM
Topic: Future of Family Medicine

So, where is the specialty of Family Medicine headed? It seems that
at every corner, Family Physicians are becoming less and less
prevalent. Over time, less and less Family Docs did OB, now fewer are
doing in-patient work. How is it that our Society/College/National
organizations have allowed this parsing to take place? And, more
importantly, where will "Family Medicine" be in another year?

I recall a comment my GP (that's what the term was then) made to me
at my sister's wedding in reference to the Hospitalist movement; "why
is it that when a patient is the sickest and needs their Doctor the
most, their Doctor abandons them to someone else?". This comment
continues to stick with me whenever I hear of another Family Doc
"gives up" their hospital work.

Comments?

Date: December 8, 2005 5:12 PM
Topic: Can't quite believe it

Can't quite believe this article, but seems to be "open hunting
season" on Physicians (ie, more and more articles like this coming out)

http://www.msnbc.msn.com/id/10349325/

See, the problem I have with this article isn't that I support this
particular Physician's "fee", but moreso that the author failed to
comment on the global "shafting" Physicians are taking. Let me share
a few examples....

1. Insurance company's frequent changing of the rules, altering
physician billing, undercutting physician reimbursement
2. Dropping Medicare reimbursement to Physicians, in particular,
Family Physicians
3. Pending "pay-for-performance" requirements for reimbursement.
While I agree with being "paid" to provide excellent medical care,
why is it that I should be "punished" (ie not reimbursed) if a
patient refuses the recommended medical care?
4. Decreasing graduate medical education funds for the training of
new physicians
5. "bundling" by insurance companies, that is refusing to pay for
more than one service on the same day
6. the list continues

Comments?

Date: July 6, 2006 6:42 PM
Topic: Beginning of a new year

So, it's about this time of the year when the hospitals are flooded
with new resident physicians, affectionately called "interns".
Fortunately for us, we have a great new group of vivacious and
energetic resident physicians who are now in the midst of the first
real week of residency (okay, week #2, but who's counting the typical
orientation material anyway?)

This is also the time of year when graduating residens enter the vast
world of attending-dom. The buck stops with them now.

As each enters their own phase of their new lives, what should they
look forward to?

Well, gone are the completely endless nights of call and >24 hours
per shift (I had the dubious privilege of being the last class to
experience this wonderous opportunity), however, our "new" physicians
will begin to experienced the glorious world of prior authorizations,
preferred medication list

Date: July 26, 2006 12:52 PM
Topic: Sorry, no payment

So, the Government decides that Physicians and Health Care
Organizations will just have to do without

September is payment free

Interesting that the Government is able to make this unilateral
decision when, if the situation were reveresed, they certainly
wouldn't feel the same way (can I skip a few days worth of bills?)

Date: August 29, 2006 4:38 PM
Topic: Call me paranoid

I'll admit that I can be a bit on the paranoid site when it comes to
the integration of technology in our lives, but this (VeriChip Sells
First Baby Protection System) really got my attention.

I remember, several years ago (in fact little over a decade) reading
a snippet from a purported conspiracy newsletter than made mention of
this technology and the eventual integration into our daily lives.
Now, although this article paints the picture of safety, I can't help
but wonder what devious plans the great "Big Brother" powers may have
for technology such as this.

Will there come a day when such implanted technology is required?
What is there to stop this eventuality?
Blogged with Flock

Date: September 2, 2006 11:52 AM
Topic: "Primary Care Physician"

I do not practice "Family Practice" nor do I see patients in a
"clinic". For that matter, I am not a "Primary Care Provider", but
rather I provide medical care to a wide range of ages; birth to
death, unfortunately taxes in between. So what is the best title to
have? Am I a "GP" or an "FP"?

Rather than words, it's actions which define who someone is...take
for example the thousands, likely millions of people who wear gold
crosses around their neck, yet their actions do not represent the
tenets of "Christianity". Or perhaps, the "Republican" who claims to
be a conservative, yet abhors "conservative values". Perhaps the
"Liberal" who preaches tolerance, yet won't let citizens express
philosophical/political/religious views which differ from their own.

One of the problems in "Family Medicine" is that this specialty
(which historically served as the foundation for nearly all other
specialties) is allowing itself to be labeled by those who know very
little about what it means to provide the "full spectrum of care".

Take for example the following "definitions" for "Family Medicine"
from a variety of specialites...
-Pediatrics: something other than kids, unless of course the young
lady begins her menstrual cycle when she should, of course, see a
gynecologist
-Internal Medicine: obviously nothing overly complicated as they
don't have the expertise in managing chronic disease that our
specialty training offers
-Obstetrics: something other the pregnant women who should only see
our specialty, that is unless I hire a CNM whom I have given
clearance (c'mon CNM's fight back!)
-Gastroenterologists: just don't do colonoscopies or endoscopies.
These are very trick procedures...what you've done 1000? Well, when
you reach 2000, I'll reconsider
-Cardiology: just don't read EKG's
-Hospitalists: yes, when your patients are the sickest and need to be
admitted, you should really turn them over to us, after all, it's a
financial loss for your office if you "have to" care for your own
patients

Shall I go on?

The specialty of "Family Medicine" needs to grow a big set of
cajones. We need to revitalize the specialty and reinvigorate the
masses. We need to stop allowing other forces (hospitals, insurance
carriers, specialites, media, impotent colleagues) to define who we are.

Date: August 29, 2007 11:29 AM
Topic: MacJournal

Date: July 26, 2006 12:52 PM
Topic: Sorry, no payment
So, the Government decides that Physicians and Health Care
Organizations will just have to do without
September is payment free
Interesting that the Government is able to make this unilateral
decision when, if the situation were reveresed, they certainly
wouldn't feel the same way (can I skip a few days worth of bills?)
Date: August 29, 2006 4:38 PM
Topic: Call me paranoid
I'll admit that I can be a bit on the paranoid site when it comes to
the integration of technology in our lives, but this (VeriChip Sells
First Baby Protection System) really got my attention.
I remember, several years ago (in fact little over a decade) reading
a snippet from a purported conspiracy newsletter than made mention of
this technology and the eventual integration into our daily lives.
Now, although this article paints the picture of safety, I can't help
but wonder what devious plans the great "Big Brother" powers may have
for technology such as this.
Will there come a day when such implanted technology is required?
What is there to stop this eventuality?
Blogged with Flock

Date: September 2, 2006 11:52 AM
Topic: "Primary Care Physician"
I do not practice "Family Practice" nor do I see patients in a
"clinic". For that matter, I am not a "Primary Care Provider", but
rather I provide medical care to a wide range of ages; birth to
death, unfortunately taxes in between. So what is the best title to
have? Am I a "GP" or an "FP"?
Rather than words, it's actions which define who someone is...take
for example the thousands, likely millions of people who wear gold
crosses around their neck, yet their actions do not represent the
tenets of "Christianity". Or perhaps, the "Republican" who claims to
be a conservative, yet abhors "conservative values". Perhaps the
"Liberal" who preaches tolerance, yet won't let citizens express
philosophical/political/religious views which differ from their own.
One of the problems in "Family Medicine" is that this specialty
(which historically served as the foundation for nearly all other
specialties) is allowing itself to be labeled by those who know very
little about what it means to provide the "full spectrum of care".
Take for example the following "definitions" for "Family Medicine"
from a variety of specialites...
-Pediatrics: something other than kids, unless of course the young
lady begins her menstrual cycle when she should, of course, see a
gynecologist
-Internal Medicine: obviously nothing overly complicated as they
don't have the expertise in managing chronic disease that our
specialty training offers
-Obstetrics: something other the pregnant women who should only see
our specialty, that is unless I hire a CNM whom I have given
clearance (c'mon CNM's fight back!)
-Gastroenterologists: just don't do colonoscopies or endoscopies.
These are very trick procedures...what you've done 1000? Well, when
you reach 2000, I'll reconsider
-Cardiology: just don't read EKG's
-Hospitalists: yes, when your patients are the sickest and need to be
admitted, you should really turn them over to us, after all, it's a
financial loss for your office if you "have to" care for your own
patients
Shall I go on?
The specialty of "Family Medicine" needs to grow a big set of
cajones. We need to revitalize the specialty and reinvigorate the
masses. We need to stop allowing other forces (hospitals, insurance
carriers, specialites, media, impotent colleagues) to define who we are.

Date: August 30, 2007 12:22 AM
Topic: Learning along the way

As many of you know, come October 1, 2007, I'll be heading into the
wonderful world of "private practice". As someone who prided himself
in constantly being educated in the areas of practice management,
billing and coding, etc, it's actually been a very frustrating
experience.

Not frustrating from a lack of understanding, but rather from the
fact that I have ZERO negotiating power. Third party payors are
holding nearly all the marbles. Now, this is certainly not a posting
to advocate for a single-payor healthcare system, which would be a
complete disaster, but rather a deeper realization of how bass-
ackwards the "system" is.

For example, typically when you "contract" with someone to perform a
job, the involved parties agree on some basic tenets...I'd like to
have the project completed by such-and-such a time and I'd like it
done within certain parameters; sky blue, not navy blue; all 4 walls
rather than just 3. I'm not going to dictate to you how you actually
paint a wall, but rather judge the work process by the end result.
This is not the case with the "practice" of medicine. Over the next
few blog postings, I'll be sharing some seemingly odd discrepancies
in the professional agreements or "contracts" physicians have with
payors (ie, insurance carries), but let me begin with a payor near
and dear to my heart (cough - cough)....Medicare.

About 2 months ago, and knowing I would be moving into private
practice, I contacted our lovely government-run insurance carrier.
You know one of the ones which we as tax payers dump loads of money
into? I contacted them seemingly far enough in advance to prevent
any delay in the "credentialling" process and to ensure that all of
my contact information, etc was updated.

As I would be forming a group practice, I would need to apply for a
Group NPI (national provider identification) on top of my already
existing personal NPI, UPIN (universal physician identification
number) and Medicare ID number. Now one would think that a single ID
# would suffice. "We" were told that at some point it
"will" (although everyone was supposed to adopt this new-and-improved
system in May, 2007) be adopted as THE number physicians and
provider are assigned and all previous numbers would evaporate.

So, like a good little compliant physician, I complete the...hmmm...5
forms??? and submitted then, as directed and with enough advance
notice that by opening day everything would be in order.

This past Monday I received notification that I had submitted my
paperwork "too soon" and would have to resubmit every wonderful piece
of paperwork within the "mandated" 30-day window. Now here's one of
the catches...you can't submit it until within 30-days of your new
office, but Medicare has up to 120 days to review and if everything
is in order, stamp the necessary paperwork with the almighty
"approved" designation.

When I questioned the representative about this because frankly it
doesn't make sense that I had to submit the documents within 30 days,
but they can take an additional 90 to "review things", I was, in so
many words, told....silly Doctor, Trix are for kids!

So, my options at this point include:
1. crap load of prayer that everything will be in order
2. float the gov't a loan by seeing Medicare patients over the next
couple of months and provided all of my documents are in order,
submit the claims afterward. So, if I see half a dozen Medicare
patients.....let's do the math....heck, it's too late for math, but
the long and short of it is that I'll be dutifully providing medical
services which may or may not be reimbursed in a timely fashion and
not until after it's been proven that I am a physician and in fact,
do care for Medicare patients.

An additional frustration is that this is now the 3rd time I've had
to go through this process in the past 5 years. I feel fortunate
because I have way too much time on my hands and I couldn't be more
thankful that the gov't gives me the opportunity to keep myself
occupied with the revolving door of credentialling.

Now, of course, it is now 48 hours + since receiving the notification
above and although I was assured that "I'll call you back", I've not
heard hide nor tail of the representative (or stand-in) that I spoke
with. Patients is a virtue, but really.....

So, we'll see what happens over the course of the next day or so and
hopefully if I don't get a response by Friday, see if anyone actually
remembers the on-going conversations I've had this week and last

Stay tuned........