Link Fest: Updates on group visits, RVUs, Medicare and the ‘Physician Shortage’

I’ve been storing up some links and today seemed to be a good time to have at ’em!  They range from the scary (Health Policy and Market) to the fun (the Efficient MD’s slide show.)

Read The Country Doc Report for another take on the group visit.  Country Doc relates how his practice does a group diabetic visit.  He uses smaller group sizes, and describes the three phases of the visit. 

For  an RVU Review, and exactly WHAT the RUC is, and how it effects you, visit Health Care Renewal blog. Boy, did I learn a lot about how we as physicians get paid (or not, as the case may be!)

To increase your understanding of the complexities of Medicare, Medicare Advantage, and Medicare Gap, see Insure Blog.  You may want to have this posted at  your front desk as patients come in with their “red white and blue” cards.

Now there are two types of Medicare plans, Traditional Medicare (administered by the government) and Medicare Advantage Plans (administered by private insurance companies). This has led to an unbelievable amount of confusion.

I love ways to improve my efficiency, and enjoyed the  fun, short  The Efficient MD’s  slide show.  I love his blog, and wish he would post more often!

For a chilly take on the role of physicians in the future, visit The Health Policy and Market blog.  According to the blog, we have plenty of doctors, and a “federal physician workforce policy” should be in place.  Just what I want, the federal government interfering even more into the business of health care! 

Establish a federal physician workforce policythat achieves the goals of organized care. TDI research has shown that the U.S. does not need more physicians; we have enough to care for America’s needs well into the future.

Let me know YOUR favority business of health care posts and I’ll put ’em up!

Group Visits: Treadmill Medicine or Meaningful Encounter?

I have been encouraging physicians to explore group visits for a while.  Group visits are especially suited for stable patients with chronic disease–think hypertension, diabetes, COPD. Patients with chronic diseases make up the majority of the primary care office visits, especially for internists.  Group visits can increase patient and physician satisfaction, and encourage healthier patients and lifestyles.

Following is a short primer on what must go into a group visit:

  • Privacy issues must be addressed.  The patient must sign a confidentiality form, allowing their case do be discussed in a group, and also agreeing NOT to discuss other patients’ medical issues outside of the group appointment.
  • The chronic disease addressed must NOT require the patient to disrobe.  (Duh.)
  • A physical exam must be done.  In order to bill appropriately, a nurse should document vital signs for each patient, and the physician should document an appropriate exam for the problem.
  • Patients should be encouraged to have questions formulated for the physician ahead of time.  These questions may be posted on white board and reviewed through out the meeting.
  • Physicians should be prepared to answer questions as they examine each patient.  This is where the efficiency exists–many of the patients will have the same questions, and will be relieved that they are not the only one with questions/problems.
  • Time should be available after the group appointment for individual questions ON THAT SPECIFIC DISEASE PROCESS.
  • Schedule enough time and enough patients.  Eight or nine patients in one hour is a good number.  You may need to have the initial group visits be 2 hours and discuss how the group visit will run.  Realize that Seniors tend to have more flexibility as to scheduling an hour long visit, while working folks may require early morning, lunchtime or late afternoon appointments.
  • Have enough support staff to take vital signs, sign privacy statements and get patients situated.
  • Be prepared for emergencies–if Mr. Pickwick shows up for the group visit with a pulse ox of 70%, be prepared for how you will handle the emergency AND  the group meeting.

As to billing issues: each patient is billed as if seen individually, hence the emphasis above on vital signs, appropriate physical exam, lab tests, level of decision making etc.  Utilize E/M codes 99212-99215 as appropriate.  Documentation is key here.  Consider a check list form, or a template for your EMR, that patients fill in regarding symptoms and questions, and then a check off form for the physical examination.

So what do patients think of group visits?  About 75% of patients that have participated would do so again, and 5% would not. 

I personally have done group visits with diabetics, and enjoyed it tremendously.   We served lunch at the first meeting, and had a nutritionist and pharmacist there as well.  The patients enjoyed it, and learned a lot.  I think group visits will go a long way towards easing the treadmill approach we employ in primary care medicine, and encourage physicians to try it.  Some practices delegate this to the “mid-level” providers, but I think patients get more out of the group visit when it is physician run.  I also believe that most physicians enjoy the interaction and ‘teaching moments.’

Let me know if you do this, and what works or doesn’t work.

For an overview of how Harvard Vanguard Medical Associates is doing group visits, see:  http://www.boston.com/news/local/massachusetts/articles/2008/11/30/the_doctor_will_see_all_of_you_now/?page=2

For more information, forms, and another in-the-trenches view point, see: http://www.aafp.org/fpm/20040900/39grou.html

What if Starbucks billed like ICD-10?

Ah, yes, ICD-10 is coming!  Yes, the new coding system with 10 times more codes than the previous is slated to go live in 2011.  Much of the world now uses ICD-10 because it has more codes, as apparently, we are running out of codes.  You, my beloved provider, will be shouldering the burden of the cost to implement the system.   A few reasons why this has made my normally smiling face curdle with disgust:

 

1.  There are TEN times more codes– all codes will be 7 digits, and then, yes, oh yes! You can add a modifier.  Simple, huh? 

“We are just now beginning to learn the increased costs on physician practices associated with moving to the ICD-10 code set – and they are staggering,” said William F. Jessee, MD, FACMPE, Medical Group Management Association president and CEO.

2.   It ain’t cheap.  Implementing the new coding system is estimated to cost $83,290 for a THREE physician office.  (See http://www.aapc.com/news/index.php/2008/10/icd-10-cm-coalition-press-release/).  At an average reimbursement of $50 per patient visit, that’s an extra 555 visits per year, per physician.  If a physician works 5 days/week, 48 weeks per year, this makes an extra 2.3 patient visits PER DAY!  If patients already feel rushed during their visits, think of it now!  And you know what, there’s not a dang thing the physician can do about it!  (Well, I guess concierge medicine might look more attractive…)

 

3.   You will wait even longer to get paid.  CMS (Center for Medicare and Medicaid Services), which is the government agency behind this change, notes: “…putting in the new system could initially boost by 10% the percentage of claims insurers return to doctors because of coding errors.“   (See http://blogs.wsj.com/health/2008/11/11/look-out-docs-here-comes-icd-10/)

 

4.   It’s another blow to primary care.  Many primary care offices are solo practitioners, or small groups (three or less.)  These are the groups least able to shoulder the cost of another complex government regulation. 

 

5.   You won’t have time to implement it.  You will need to learn the new codes, educate your staff, update your super bills and then change over your billing software to accommodate these new codes.   Most importantly, you will need to do some major cash flow planning.  (Yup, adding in an extra 65,000 codes takes time and money!)  This will be tough to do given the time frame the CMS is proposing.  Even the insurers want more time.  (Who’d a thunk it—me agreeing with medical insurance companies!)

 

6.   Get ready to buy more computers.  If your practice wants to be efficient, you will need computers in each exam room to quickly file the charges.  This is on top of the mandate that medical practies move to an EMR.  (Who’s going to fund THAT?) (See: http://www.ama-assn.org/amednews/2008/09/08/gvsa0908.htm).

 

7.   Beef up your documentation.  You want to get paid?  Prepare to be exacting!  The reason for a medical chart has changed—it used to be so that we could develop a working diagnosis and plan, based on history and exam to treat a patient.  You poor dinosaur! A chart is a way to get paid! 

 

8.   It will drive up the cost of health care.  The cost of soft ware, computers, training, IT support and the like will first be passed to physicians, and then eventually to patients.  There is no such thing as a free lunch!

 

9.    Patient care will suffer.  As physicians, we are ever more focused on computers, documentation, crossing Ts and dotting I’s.  Who will focus on patients when we are focused on coding?

 

10.   We will lose more primary care physicians.  Small practices, in rural/underserved areas can not afford the implementation involved in transitioning to ICD-10.  Implementing  ICD-10 will be a nail in the coffin of areas that desperately need primary care physicians the most.

 

I was thinking about opening a coffee shop.  I could code and bill for beverages as follows: a small cappuccino would be a 99212(01), a medium 99213(02), and a large a 99214(03), and jumbo would be a 99215(04).  I could add modifiers to denote skim, 2% or whole milk.  Shots of flavoring would require modifiers as well. So, a medium, skinny cappuccino with a shot of hazelnut would be a 99213(02)-7-13  (taking into account the ‘skinny’ or -7 and the hazelnut -13.)  I would of course charge you, the customer, more for my nifty billing system.   I also could bill based on how LONG it takes to make the beverage.  I don’t know why Starbucks doesn’t do this.  It seems so efficient.

Billing for Phone Calls: Acceptable Practice or Reptilian Behavior?

My trusty health insurance, for which I pay handsomely, (yes, I am self-insured) sent me an email titled, “Calls could cost you.” It states that calling your physician may cost you. I quote:

“Many times people call their doctor to ask a question, resolve a concern, or ask about a referral. Traditionally, doctors haven’t charged to answering these questions. In certain cases, that’s changed.

New rules have been established that allow doctors to charge for telephone consultations in some circumstances. To be a billable call, the patient must not have been seen by the doctor for a week before the call or within 24 hours after the call. If the doctor provides services that could have happened at a regular office visit, then the doctor can submit a claim. The doctor must let the patient know the call isn’t free and that he or she intends to bill.

If the doctor does submit a claim to Humana, we’ll treat it as if the doctor filed a claim for an office visit. So if your benefits have co-payments for an office visit, you’d owe the doctor your co-payment for an office visit. If your Humana plan has a deductible, we’ll apply the allowable claims costs to your deductible. You’ll pay the allowed charges, unless you’ve met your deductible.

These rules don’t apply to most calls people make to their doctor. But Humana wants you to know that under current national rules, doctors can bill both Humana and their patients for some telephone visits.

It’s important to know that calling your doctor could cost you in some circumstances. If you’re aware of the rules, you could save yourself some money.”

Hmmm, this is interesting. What patients should you manage over the phone? What are the legal ramifications? Ethically, what is involved in charging for phone calls?  God forbid, are we behaving like lawyers? I don’t know about you, but I always prefer to see a patient rather than prescribe over the phone. I know some patients absolutely refuse to come in, “I don’t have time,” but I am loathe to diagnose and prescribe over the phone.    (And these are the patients I think are most likely to sue-they seem to be looking for a way to work around the system.)

My take-
If a patient is ill they need to be seen.
If you are going to bill for phone calls, and it is certainly justified in some cases, be impeccable in your documentation.
Establish criteria ahead of time of what sorts of phone calls you will bill for, and what cases ABSOLUTELY must be seen in the office.
Teach your staff how to triage calls.

Following are the codes for phone calls.  (From From the January ACP Internist, copyright © 2008 by the American College of Physicians.)  If anyone is doing this, I would love to hear back as to which insurers are reimbursing, and how you determine which patients are appropriate to be managed by phone–e.g.  coumadin management? 

99441: Telephone E/M service provided by a physician to an established patient, parent, or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; five to 10 minutes of medical discussion
99442: 11-20 minutes of medical discussion
99443: 21-30 minutes of medical discussion

As to liability, here are some guidelines from CRICO/RMF, the medical malpractice company for the Harvard Medical Community.  (http://www.rmf.harvard.edu/patient-safety-strategies/communication-teamwork/telephone-technology/faqs.aspx#Q31)

“Documentation of all phone calls in which medical information is discussed is extremely important. The date and time of the call, patient’s complaints, and advice given should all be recorded. The advice given should include the point at which the patient should seek medical attention. The few minutes taken to record this information will be valuable for ongoing patient care. In the event a patient challenges the quality of medical care they received by phone, or claims he or she made multiple calls and received no or inadequate advice, such documentation will prove worthwhile.”

Good luck with this!  I think that coding for phone calls has a lot of potential for good and bad, and would tread lightly.  And just to make you smile, I got an automated phone call from Humana while I was writing this, encouraging me to visit their web site, where I could get medical advice “tailored for me.”  Shoot, who needs an MD?  Just throw up a web site with generic advice and call it a day!

Resuscitating Primary Care: Part II

All right, pencils out, notebooks at the ready!  Quiz to follow!  Here is Part II of Resuscitating Primary Care.  At our last session, we noted the primary care was indeed a “code-blue/COR-0”.  As promised, I will apply my laser sharp focus to “fixing” this problem.

Buckle up!

You are a shrink. This is another unavoidable issue.  You must learn effective ways to help these patients, which make up a large part of medical practices.  In our medical school and residency programs there needs to be a greater emphasis on psychiatry, as mental illness is so pervasive.  As to your own practice, several things will help: learning and using the counseling codes, scheduling enough time for these patients, and having on hand the cards of your favorite psychiatrists, psychologists, and social workers.  Also, you must become well versed in the plethora of antidepressants out there.  Key point: you have limits too, and remember that most mental health professionals have the phrase down, “I’m sorry, but our time is up.  When should we schedule our next visit?”

Insurance companies make life miserable.  We must fight back!  As group, we physicians have laid down and played dead!  From a macro level, we physicians need to lobby for appropriate reimbursement and STOP accepting what ever insurance companies offer.  (See related post: “Entering the Lions Den”.)  At a practice level, your job is to ensure that your coding, billing and collections are top notch.  That means knowing which insurers are paying in a timely fashion, at an appropriate rate. It means dumping the ones that aren’t!  It also means negotiating for the reimbursement your work deserves. It means having a strong stomach, and realizing that this problem is not going to go away unless you make it go away! 

It’s not good mind candy anymore.  Ahh, to find the random pheo and look like a hero!  The reality is we are managers of chronic disease, cheering patients on when they lose weight, lower their A1-C and actually exercise.  Yes, you will still make the occasional brilliant diagnosis, but your focus will be on medical coaching.  You need to learn how to coach, and find joy in it.  Another avenue to explore would be group sessions, which can be energizing and exciting.  Next, you could market your practice as “the practice for the seriously ill” — meaning you WANT complicated medical patients.  This has ramifications for billing/collections, but could be a viable model.  (Note: I haven’t run the numbers, but remember, you will code higher for more complicated patients.  If you really market your practice to get these patients, it may be fairly interesting. Any one out there have a practice like this?)  Lastly, consider leaving slots open for urgent care visits.  There is no reason to give this business away to Urgent Care clinics, and these visits can be fun and interesting.  (Yeah, I know, you will see a lot of URIs, but you will also see the occasional thyroid storm and aplastic anemia!  Been there, done that!)

The environment is hostile.  But you don’t have to be!  If you are on time, sit down, look AND listen to the patient a lot of hostility will vanish.  We have perpetrated some of this, and it is completely fixable by physicians!  Bedside manner, (Marcus Welby, not House!) is where it’s at.  Please, do not hide behind your computer.  Yes, use that high falutin’ super expensive EMR, but set it up so that you can look at the patient and type.  For pity’s sake DO NOT write notes and type them in later! Talking about a huge time waster!!!  Make your exam room and waiting room comfortable, and a friendly receptionist and nurse are a must.  Sourpusses need not apply!

Not everything is fixable.  Yup.  However, our mind set must be that our job is to guide patients toward health, and that there are no quick fixes.  Part of the job is to move patients towards this mind set as well.

Key point of this post:

Make it fun!

We spend too much of our time at work not to have fun. Have a good time with your patients and staff.  When the end of the day comes, I think the one that had the most fun, wins!  Hang in there, send comments on how to make it better, lobby for change, and keep doing the good work!

PS:  I will put up a page with a resource list in the next few days.

Resuscitating Primary Care, Part I

 
As promised, I will turn my laser like focus to the task of “fixing” primary care.  I will examine both micro and macro ways of doing this, coming up with to do lists that physicians can implement in their practices as well as global suggestions that will take shifts in health care policy.  (Which only we as a group of physicians can enact!)

1.  The pay stinks. Yes it does.  Physicians do not get pay raises because they are more experienced or incredibly good.  The only way to increase the pay is to do one of three things: see more patients, add more services and globally lobby for getting paid for thinking (which is what primary care physicians do best).  At the practice level, you need to examine patient flow, appropriate billing for services rendered (example: are you billing/coding appropriately for immunizations?) and decide on an appropriate number of patients to see.  Calm down, I am NOT telling you to become a patient care mill, rather to be realistic and set a REASONABLE number of patients you could see.  Also realize that the pay is limited, and it will take a major change in reimbursement to get paid appropriately for what you do.  (Sorry, it is what it is.  Get out there and lobby for change!)

2.  You got an MD instead of an MBA.  I am addressing this early in the game because it is probably the most important.  In my neck of the woods, massage therapists, as part of their curriculum, learn marketing and accounting.  They are better equipped to set up a practice then a physician who has spent 4 years in medical school then 3 more in residency! (Academic medicine, are you listening?) Here is the big message of this post:

You must learn the business of medicine.

But how?  There are books on practice management, seminars on practice management, journals on practice management, and a good accountant and bookkeeper are essential.  But YOU must understand the financial underpinnings of your practice, even if you have God’s gift to office managers.  (For more on seminars, visit my website: www.extramd.com.)  Later this week, after I do my nights shifts, I will put up a page with a list of resources I found helpful.  C’mon, as a physician, you are used to soaking up knowledge like a sponge, you can do it!

 3.  Coding is really fun.  Sorry, but this is another one you MUST learn.  I don’t care that it is boring, picky and strong medicine even for the most confirmed of insomniacs.  Once again, avail yourself of every resource you can to learn it.  Think seminars, books, consultants.  No whining, just do it.  (And remember, ICD-10 is coming.  Sheesh.)

 4.  You are a hamster on a wheel.  You will have to weigh revenues vs. practice style here.  Of course, you will need to maximize revenues, billing and collections no matter what you do.  However, if you choose to see fewer patients per day, then you need to reconcile yourself to less revenues, and ultimately less income.  Your practice partners may have some input on this (!), but if you are solo, consider the micro practice model that is getting a fair amount of hype.  Whatever you do, be very clear in your mind what your expectations are.

All right, enough for today.  We will continue PookieMD’s crash course on primary care resuscitation in my next post.  Until then, keep the doors open, and get out and learn a little about the business of medicine!